Background An inpatient developed a grade 4 pressure ulcer, however, inadequate documentation demonstrating the on-going management and escalation of the incident made it difficult to answer both the patient and their family’s questions. The incident was escalated to the relevant bodies and an internal investigation undertaken. The hospice and the patient’s family were keen to ensure lessons were learnt and that changes were made to improve documentation.

Aim To develop an effective process and training programme ensuring comprehensive documentation of patient care.

Methods Mandated documentation training focusing on clinical standards and the implications of poor record keeping was jointly developed with Her Majesty’s Coroner and delivered at the Coroner’s Court. A Clinical Documentation Management group was developed at the hospice to provide strategic direction and control.

A multi-disciplinary audit tool was developed to evaluate patient records and a six-monthly audit cycle established. Real time feedback highlighting positive practices and areas for improvement was provided to managers and clinicians. Results of the audit indicated changes were required within the documentation process; all paper assessment forms were reviewed and a standardised format created. Electronic forms were reviewed to ensure compliance with the updated documentation policy and a standardised abbreviation list created to ensure consistency.

Documentation training was introduced for new members of staff and a mandatory training programme provided using redacted patient records. Multi-disciplinary groups worked together to answer key clinical enquiries which were representative of issues investigated by a Coroner.

Results On-going audits demonstrate incremental improvement in documentation and to ensure standards are being maintained there are plans to introduce a peer documentation review process and record keeping champions.

Conclusion The development of a robust document management process, training and audit programme is fundamental to ensuring high standards of documentation and the delivery of high quality care.