RT @NHS_Lothian: ❄️ Most of us have woken up to a lovely winter wonderland this morning. Our hospitals are under extreme pressure at the mo…
Best practice for making entries in the CPES© Log books
Best practice in record keeping is the 'gold standard' towards which all NHS staff should aim. Judges expect that persons making log entries will comply with this standard.
A comprehensive record must be kept of all events, information received, decisions, reasoning behind those decisions and action taken.
It is important that a nominated information manager be made responsible for overseeing the keeping and storage of the records and files created during the patient evacuation or reception response.
This also applies to Emergency Log Books©, Decision Log Books© or other records used by on-call managers to record issues, information received and action taken in the minutes, hours or days leading up to the decision to authorise patient evacuation.
Your entries must be C I A – Clear Intelligible Accurate.
- Relevant information should always be recorded in official Log Books.
- Write in permanent black ink. Write legibly. Avoid blue ink.
- Your record must be contemporaneous.
- Use a new Log Book for each incident.
- Ensure you note dates, times (use the 24 hour clock) places and people concerned.
- Record any non verbal communication. Do not put your own interpretation on that non-verbal communication.
- Only note down facts. Do not assume anything, give your own comment or give your own opinion.
- Entries in the record must be in chronological order.
L eaves must be torn out of the Log Book
B lank spaces – rule them through
W riting above or below lined area
- Unused space at end of a page must be ruled through with a diagonal line, initialed by you, dated and timed.
- Record all questions and answers in direct speech.
- Unused spaces at the end of lines must be ruled out by you with a single line.
- Mistakes must be ruled through with a single line and initialed by you.
- Any mistake you make which you notice at the time of writing must be ruled through by you with a single line, initialed and the correct word(s) added after the mistake.
- Overwriting or writing above the ruled through error must not be made.
Correction fluid must not be used in any circumstances
- If you notice a mistake or an omission in the record later, during the debrief, or at any other time, you must tell your senior manager and the mistake must be corrected or the omission made good. Cross reference the mistake (in red ink) to the corrected entry on the next available page using letters from the alphabet, consecutively.
- Make clear references to exhibits (such as maps, flip chart pages, etc) and other documents so that it is clear in the record which particular exhibit is being referred to.
- Each series of entries must be signed off, dated and timed at their close.
- Loggists should sign off their notes at the end of their shift to ensure the integrity of the record.