Relative discussions recorded
Health Boards should ensure that any discussion between a member of nursing staff and a relative about a patient which is relevant to the patient's continuing care is recorded.
- The Scottish Government's response detailed professional standards for record-keeping, with the revised NMC Code (effective March 2015) requiring nurses and midwives to maintain clear, accurate, and contemporaneous patient records.
- The requirement that discussions with relatives relevant to care are recorded is embedded in the NMC Code's standards on record-keeping, which apply to all registered nurses and midwives practising in Scotland. The GMC's Good Medical Practice sets equivalent standards for doctors.
- The Health and Social Care Standards (published June 2017) include Standard 3: 'I have confidence in the people who support and care for me,' which encompasses professional standards including accurate record-keeping (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- Healthcare Improvement Scotland assesses record-keeping quality as part of its inspection programme, and the Scottish Patient Safety Programme promotes standardised documentation practices including safety briefs and structured handovers.
How was this evidence gathered?
Response
Accepted
Response
AcceptedSection 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code, effective from March 2015, requires nurses and midwives to complete clear and accurate records at the time or as soon as possible after an event. This includes identifying any risks or problems and the steps taken to deal with them, ensuring colleagues have all necessary information. The Scottish Government's Records Management: NHS code of practice (Scotland) also provides guidance on required standards of practice for record-keeping.
Published Evidence
Published assessments of progress from inspectorates, select committees, official progress reports, and other sources. Source type badge indicates whether each assessment is independent or government self-reported.
Duty of Candour requires documentation of communications with patients and families about safety incidents. Excellence in Care CAIR Dashboard monitors communication standards.
View detailed findings
Statutory duty ensures discussions with relatives about patient care are documented and followed up.