CD002: Defensible Documentation – Tips for Writing Professional Progress Notes

Defensible documentation, what does this mean? This week Kell offers up some tips on writing professional progress notes and together with Carrie, discusses how to write progress notes that can support you and your organisation in the case of an audit, or if your notes are called before a law court.

Kell’s Top Tips:

1. Always check that you are writing in the relevant person’s notes

• This means making sure you have the correct‘ identifiers’.
• Identifiers are a person’s name and their date of birth.
• Never write notes on a blank sheet, even if the notes are contained within the person’s file and always ensure identifiers are noted on each individual page.

2. Use a blue or black pen

• Blue and black pens are the colours of preference for legal documents as they photocopy well and are easier to read.
• Avoid the use of red or other coloured pens as these are harder to read and do not photocopy well.
• Ensure they are indelible – this means they cannot be erased – this means you cannot use either pencils or erasable ink pens.

3. Write legibly

• Your notes need to be clear and easy to read and decipher.
• Printed words rather than cursive lettering are fine.
• It’s okay to print in capital letters if this ensures your notes are legible.

4. Note the date of your entry

• If you are writing about something retrospectively, you can include the date and time of the event within the body of the note.

5. Sign your entry

• This may be a full signature or your initials – it will depend on your organisation’s policy.
• Make sure you sign directly after your last word

6. Avoid blank space between entries

• Never leave blank lines or space between entries.
• If you have a blank line that you don’t want to write on, draw a line through it.
• If you start a new page and discover that the previous page still had white space left then draw a ‘Z’ shape through the remaining white space so no-one can write in this section.

7. Make it clear if notes span more than one page

• If you move from one page to another Add ‘Note continues overleaf’ at the end of the page.
• At the beginning of the next page add the words ‘Continued from previous page

8. Errors happen

• If you make a mistake, place a line through the word.
• Do not use white out or try to black out the entry.
• If you have made a note in the wrong person’s progress notes rule a line through the entry and make a note that the information was written in the wrong client’s file by using the words ‘notes entered against incorrect client’.

9. Use the correct words

• Do not try to write complex words unless you are sure of their spelling and meaning.
• Remember that even many simple words that sound the same are spelt differently and have different meanings.
• Plain and simple language is the best course of action.

10. Beware the acronym and abbreviation

• if you use a shortened version of a word or phrase, make sure it is either a standard across the industry, with no chance of misinterpretation, or is one approved by your organisation.
• An abbreviation is a shorthand version of a word or phrase that may be used repeatedly, Dept. = Department
• An acronym is a word or name created out of the initial letters of words in a phrase, e.g. Commonwealth Home Support Programme = CHSP.
• Use the full word/s where possible

11. Keep your entry professional

• Use no assumptions, judgemental language or red flag terminology.
• Keep to known observations, state only what you heard, saw, smelt or felt.
• Just because a person looks unhappy doesn’t mean they are sad. Just because someone is staggering does not mean they are drunk.
• When you state that someone was being offensive or obstructive, you are making a judgement call on her behaviour – someone’s behaviour might offend you but they don’t mean to. Just say what someone did and your response to that, you are maintaining professional neutrality.
• Red flag terms describe words or phrases that are sensational in nature. These could be describing a person as being the ‘victim of domestic abuse’ or ‘there is an epidemic of scabies within the household’.
• Just remember, stick to the facts and only the facts

12. Electronic progress notes?

• Content still important, don’t waffle and maintain a professional tone.
• Always log out after making an entry.

If you would like to read more detailed information about writing progress notes check out our blog post 11 Tips for writing professional progress notes

Please let us know how you found this episode in the comments below. If you have any further ideas for maintaining professional notes we’d love you to share them with us.

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