Recording Clinical Discussions

IHRD-26 Response Accepted

Recommendation

Clinical notes should always record discussions between clinicians and parents relating to patient care and between clinicians at handover or in respect of a change in care.

Published Evidence Summary

The following publicly available evidence relates to this recommendation:

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

Sources

Government response (2018-03-01): Accepted Source: https://www.health-ni.gov.uk/topics/ihrd-implementation-programme Text: Documentation standards updated to require recording of clinical discussions and handovers. Progress update (2024-01-31): Completed Implementation status based on Department of Health NI Implementation Programme updates. Source: https://www.health-ni.gov.uk/topics/ihrd-implementation-programme

How was this evidence gathered?

Evidence searched by baseline-data-v1 on 26 May 2026

Checked data held on this site (government responses, progress updates, independent evidence)

External sources searched: www.health-ni.gov.uk

This recommendation applies across many organisations. The evidence above reflects central policy activity; adoption in individual organisations may vary.

Jurisdiction

Northern Ireland

Response

Accepted

Accepted HSC Trusts

01 Mar 2018

Documentation standards updated to require recording of clinical discussions and handovers.

Read Full Response

Source

Inquiry Hyponatraemia Inquiry

Report Report of the Inquiry into Hyponatraemia-related Deaths 31 Jan 2018

View Source

Responsible Bodies

HSC Trusts Primary

Themes & Tags

Inaccurate and inaccessible patient records No person-centred care Clinical Records Communication Handover

Recommendation age 8.3 yrs

Last formal update 851 days ago