Recurring concern
Incomplete, inaccurate or unavailable clinical and care records
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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.
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Concerns raised3
Failure to record important clinical events and patient discussions
Inaccurate dates and times in clinical records
Failure to document multidisciplinary observation decisions in clinical notes
This report raised 16 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
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Action
Provide staff training on contemporaneous, high-standard record keeping through an external law firm.
Stated by Norfolk and Suffolk NHS Foundation Trust -
Action
Ensure agency staff can access electronic patient records and understand expectations to record contemporaneous notes individually and comprehensively.
Stated by Norfolk and Suffolk NHS Foundation Trust -
Action
Routinely upload the SBAR tool onto the electronic patient record.
Stated by Norfolk and Suffolk NHS Foundation Trust
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Concerns raised1
Failure to complete handover records in patients’ notes
This report raised 13 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
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Action
Implement structured SBAR handover documentation by transferring midwives, supported by a designated section in electronic patient records.
Stated by Calderdale and Huddersfield NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The established requirement for transferring midwives to document structured handovers, supported by SBAR systems and training, is considered sufficient.
Stated by Calderdale and Huddersfield NHS Foundation Trust
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Concerns raised1
Failure to maintain accurate wound tracking documentation
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.
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Concerns raised1
Lack of care notes
This report raised 10 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.
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Concerns raised1
Failure to record incidents in nursing records
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.
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
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Action
Complete documentation and record-keeping training for nursing and care staff, including policy reissue and good-practice requirements.
Stated by PrimeLife Limited -
Action
Conduct regular competency checks to confirm staff retain documentation training and demonstrate good practice.
Stated by PrimeLife Limited -
Action
Monitor documentation daily through management checks, record triangulation, spot checks and immediate corrective supervision where shortcomings are identified.
Stated by PrimeLife Limited
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Concerns raised1
Poor completion of clinical documentation
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.
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Concerns raised2
Insufficient detail about patients in clinical notes
Failure to document specific staff concerns in clinical notes
This report raised 5 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
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Action
Use and build the SBAR tool in patient records during handovers and ward reviews to capture patient history, concerns and required escalation.
Stated by Norfolk and Suffolk NHS Foundation Trust
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Concerns raised1
Failure to document the rationale for non-referral to the MDT
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to enter clinical records contemporaneously in a single clinical record
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.
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Concerns raised1
Poor documentation of sedation medication
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026