Recurring concern
Incomplete, inaccurate or unavailable clinical and care records
Pin
Get email alerts
Request correctionFirst reported 13 Dec 2008•Latest report 26 Jun 2026
What this concern includes
Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
Not included
- Information-transfer failures where the underlying records are reliable
- Documentation dedicated to a separately named safety system when that system supplies the more faithful parent boundary
- Non-care administrative records
- Reports
- 474
- Individual concerns
- 568
- Date range
- 2008–2026
- Stated actions
- 780
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
-
Concerns raised1
Poor record keeping and unavailability of patient appointment records
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Inadequate clarity, accuracy and completeness of medical and nursing notes
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Action
Revise nursing documentation and reinforce Ward Manager and Matron monitoring of documentation quality.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Audit key aspects of medical clinical documentation through the Trust’s Clinical Audit programme.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
-
Concerns raised1
Unavailability of records for patients’ ward stays
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Substandard nursing-record documentation of risk assessments before weekend leave
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Action
Implement and roll out the Informal patient leave agreement documenting doctor-approved leave, conditions, contingency plans, and signatures.
Stated by East London NHS Foundation Trust -
Action
Implement and roll out the inpatient leave checklist requiring risk assessment, family discussions, contingency plans, return feedback, and RIO documentation.
Stated by East London NHS Foundation Trust -
Action
Conduct quarterly audits of leave forms and corresponding RIO entries from July 2016 through January 2017.
Stated by East London NHS Foundation Trust
-
Concerns raised1
Insufficient recording of psychiatric patient observations and interactions
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Action
Implement purposeful engagement in adult inpatient services and require timely recording of staff interactions in clinical records.
Stated by Surrey and Borders Partnership NHS Foundation Trust -
Action
Revise the Observation Policy to require comprehensive risk assessments and documented observation decisions, risks and triggers.
Stated by Surrey and Borders Partnership NHS Foundation Trust -
Action
Review the Records Management Policy and establish standards for factual, accurate, evidence-based and timely record keeping.
Stated by Surrey and Borders Partnership NHS Foundation Trust
-
Concerns raised1
Failure to accurately record the timing of resident checks
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to record significant events and developments
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Action
Remind medical and nursing staff that record keeping must meet Nursing and Midwifery Council and General Medical Council standards.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust -
Action
Require all Trust consultants to audit clinical records as part of annual appraisal.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
-
Concerns raised1
Failure to maintain a single coherent set of clinical notes
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Action
Reiterate and reinforce the record-keeping policy requiring staff to use one current set of records during each admission, through clinical leads and governance meetings.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
-
Concerns raised1
Failure to maintain clear and sufficiently detailed electronic clinical notes
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure of assessment notes to clearly and accurately record information for the discharge decision-maker
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026