In healthcare complaints, not every action is always documented. Staff may assume that routine actions or well-intentioned interventions don’t need recording. However, missing evidence makes it difficult to reach accurate findings later in the complaint process. Memories of events—both from the complainant and staff—can differ, creating uncertainty.
HINT:
- Maintain complete, contemporaneous clinical records.
- Obtain signed and dated written statements from all staff involved.
TIP:
- Keep detailed records of all phone calls and contacts with the complainant. If decisions are made verbally, confirm them in writing and request agreement.
- Ensure statements and records are contemporaneous, or as close to the incident as possible—these are the most reliable for investigations.
- Strong evidence helps resolve complaints efficiently, reduces escalation, and supports learning for service improvement.