Good Documentation
Practices
Introduction
The work done in Blood Transfusion centres affects the safety of donors, patients and staff and for this reason it is vital that documentation is of the highest standard. Written procedures must be followed, work done must be documented and records must be kept.
The following Good Documentation Practices (GDPs) should be applied when performing daily duties across all departments.
DONOR PATIENT
Contents
• Evidence• Recording Information• Legibility• Blank Spaces• Correcting Errors• Date and Time Formats• Reporting Results• Deviations• Confidentiality• Falsification• Signatures• Meeting Timelines• Record Retention• Document Media
Good Documentation Practices
If it’s not documented, it didn’t happen!• Documentation provides proof or
evidence that something was done• Record sufficient detail so that anyone
looking at the document in future will know exactly what happened
• Each document should be able to stand alone with all required information
Evidence
Record information immediately• Don’t trust your memory because you may
forget to record the information later • Don’t write results on loose pieces of
paper as these may get lost• Don’t transcribe information from one
form to another as this could lead to errors
Recording Information
All documents must be clear and legible • Information on a document is useless if it
cannot be read and understood• Take care to write neatly and clearly • If your handwriting is not easy to read
rather print in capital letters• Use black pen only, it photocopies well &
is legal• Don’t write in pencil as this can be
erased
Legibility
Don’t leave blank spaces on forms• Fill in N/A if not applicable • Or cross out section if not relevant• Otherwise it looks as though someone has
forgotten to enter information• Do not use ditto marks as these could be
taken for number 11
Blank Spaces
Correct errors in a legible way• Draw a single line through mistakes• Write the correct information next to the error • Sign and date this • Anyone looking at the document should be
able to see what information was changed and by whom
• Do NOT try and write over the error as this makes it illegible or difficult to read
• Do not ‘colour’ over mistakes, this makes documents messy and illegible
• Never use correction fluid (eg. Tippex)
Correcting Errors
22 C 24 C Joe Bloggs 23/10/2015
Standardise date and time formats• Standardise and stipulate format for recording
dates eg. dd/mm/yyyy• Ensure everyone records dates in same way• Check that dates on computer system match
date format used on forms• Record times using 24 hour clock ie. 15:30 (not
3.30)
Date and Time Formats
Standardise the reporting of test results• Report results to same number of decimal
places as in specification• Labs to round off results as follows, when
required: - if number is below 5, round down - if number is 5 and above, round up • Apply relevant correction factors for equipment
to results before rounding off (as above)
Reporting Results
If you deviate from procedure, record details• If anything out of the ordinary occurs make
comments as to what happened• Months/years from now you may not
remember the exact details so write them down
• Document should be able to ‘tell all’ in future
• Explain deviation and why it occurred • Remember to sign and date your comments
Deviations
Confidentiality is crucial• Blood Transfusion centres must have a
policy to ensure information relating to donors, patients or staff is kept confidential
• This information may not be disclosed to any outside parties
• Access to certain information should be restricted
• Don’t share your PIN or password with anyone
Confidentiality
Falsification must not be tolerated • Information entered on a form must be
true and accurate• Results should be reviewed and checked by
a second independent person, where possible
• All errors should be corrected immediately• Action should be taken if staff are
deliberately falsifying documents
Falsification
Signatures must be traceable • One must always be able to determine who
signed a document• Always sign your name in the same way • A signature list of all staff signatures (and
initials) should be kept in each department• This list should be updated when staff leave
or new employees join
Signatures
Be aware of signature fatigue • In Blood Transfusion we sign lots of documents
so take care not to become complacent • Double check any document before you add
your signature• If something goes wrong and you end up in
court you must be able to justify why you signed something and what your signature means
Joe SmithJoe
Smith
Joe SmithJoe Smith
Signature Fatigue
Complete/ submit required documents on time• Procrastination causes problems for all• Don’t let paperwork pile up in your mailbox• Process documents promptly & get them off
your back • Review and update SOPs when due• Complete internal audit reports on time• Process corrective action reports as quickly
as possible
Meeting Timelines
• There must be a document stating how long records should be kept for according to the Standards/ legal requirements
• Don’t store records for longer than required
• Avoid duplication, don’t store documents if someone else is already keeping them
• Document storage areas should be secure
• Storage methods must prevent possible damage
• One must be able to retrieve documents from storage in reasonable time if needed
Record RetentionStore records safely for stipulated periods
GDPs apply to all types of document media• Includes paper/ hardcopy records with
written data and a handwritten signature• Also includes electronic records which are
completed on-line and signed electronically • Same applies to hybrid documents ie.
electronic documents filled in on-line but then printed out for a written signature
• With time more & more of our documents will become electronic. Hooray!
Document Media
For the safety of staff, donors and patients:
Do what you document and document what you do !
Thank you