Recurring concern
Unreliable completion of admission documentation
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Request correctionFirst reported 3 Sep 2014•Latest report 28 Aug 2025
What this concern includes
Includes failures in the dedicated admission-documentation process, including unclear or inadequate completion protocols, missing or delayed care plans, risk assessments and other required admission records, and failures to complete or update those records during admission.
Not included
- Excludes general clinical or care-record deficiencies that are not specifically connected to admission documentation.
- Excludes failures in the substantive clinical admission assessment where the admission documentation process is not deficient.
- Excludes discharge, transfer and post-admission documentation processes unless the assertion specifically concerns completion of required admission documentation.
- Excludes generic staffing, training or communication deficiencies unless they directly impair completion of admission documentation.
- Reports
- 15
- Individual concerns
- 15
- Date range
- 2014–2025
- Stated actions
- 22
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 raised1
Failure to complete falls risk assessments within the first 24 hours of ward admission
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.4
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Action
Require falls risk assessments within 12 hours of admission, with weekly or condition-triggered reviews, and display patient risk status at the bedside.
Stated by Somerset NHS Foundation Trust -
Action
Monitor falls risk assessment compliance through monthly Core Nursing Metrics audits and additional spot audits.
Stated by Somerset NHS Foundation Trust -
Action
Use an acute medical unit admission checklist to contact families, care homes or community hospitals and gather baseline information for risk mitigation.
Stated by Somerset NHS Foundation Trust
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Action
Improve Intentional Rounding through role modelling, a patient-centred real-time documentation tool and rollout of the new form across the acute medical unit.
Stated by Somerset NHS Foundation Trust
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Concerns raised1
Failure to record lying and standing blood pressure on admission
This report raised 8 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
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Action
Assign a falls champion to each ward to educate staff and check completion of required lying and standing blood pressures.
Stated by the Rotherham NHS Foundation Trust -
Action
Assign a healthcare assistant on every shift to ensure required lying and standing blood pressures are completed.
Stated by the Rotherham NHS Foundation Trust
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Concerns raised1
Lack of practical arrangements to ensure patients are weighed on admission and the information documented
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.1
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Action
Develop and trial a cross-site live dashboard showing ward compliance with timely patient weighing.
Stated by Bedfordshire Hospitals 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 Trust cannot currently provide more costly weighing equipment because it lacks the available financial resources.
Stated by Bedfordshire Hospitals NHS Foundation Trust
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Concerns raised1
Failure to complete VTE risk assessments on admission to the in-patient unit
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.3
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Action
Reinforce the importance of completing VTE assessments through staff communications.
Stated by East London NHS Foundation Trust -
Action
Review admissions daily or during weekend huddles to confirm VTE risk assessments, and audit those assessments fortnightly.
Stated by East London NHS Foundation Trust -
Action
Add a mandatory VTE-risk screening question to the Observations and Measurements form, preventing electronic-record completion until answered.
Stated by East London NHS Foundation Trust
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Concerns raised1
Lack of guidance on the timeframe and steps for completing the Seven-day short stay booklet
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.
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.4
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Action
Review and reprint the seven-day booklet with instructions to complete pages 1–14 within 24 hours, check daily, and explain any gaps.
Stated by Surrey and Sussex Healthcare NHS Trust -
Action
Continue monthly documentation audits to monitor booklet completion and identify ward or individual training requirements.
Stated by Surrey and Sussex Healthcare NHS Trust -
Action
Create and deliver a simulation video demonstrating a perfect admission, including patient engagement and completion of the seven-day booklet.
Stated by Surrey and Sussex Healthcare NHS Trust
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Action
Roll out digital documentation incorporating the seven-day booklet content into an electronic record with clinician access and timed completion tasks.
Stated by Surrey and Sussex Healthcare NHS 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
A definitive booklet-completion timeframe cannot be provided because admission pathways, admission times, patient capacity and presentation vary.
Stated by Surrey and Sussex Healthcare NHS Trust
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Concerns raised1
Inadequate protocols for completion of admission documentation
This report raised 15 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
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Action
Train nurses and shift leaders on documentation, care plans, wound management, assessments, body maps, consent forms and hospital-return documentation.
Stated by Hill Care Group -
Action
Review admission documentation and initial care plans to ensure they fully and accurately record service users’ needs.
Stated by Hill Care Group
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
Existing protocols for wound management and required care documentation are considered sufficient, with compliance monitored through regular audits.
Stated by Hill Care Group
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Concerns raised1
Failure to complete risk assessments within 24 hours of admission
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 complete care plans and risk assessments after admission
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.
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Concerns raised1
Poor quality of admission documentation
This report raised 9 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 complete medication summaries during admission clerking
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.
Data last updated 7 September 2026