Within the NHS there is a legal requirement that all clinical information is recorded in clinical notes as part of formal information governance procedures. Yet the recording of some patient information in everyday clinical practice remains outside the domain of ‘formal’ and takes the form of more ‘informal’ recording, through the documentation of information within so-called ‘handover lists’ for shift changes. Anecdotally, it is suggested that this practice occurs mainly among junior doctors and ward nurses, where patient information is documented and communicated to staff through either electronic means or on hand-written sheets, and then disposed of. Very little empirical knowledge exists about this practice and given the growing importance of the legalities surrounding clinical information, there is an urgent need to gain a better understanding of the behaviour surrounding its occurrence, in order to align it to governance and ethico-legal requirements.
This nine month study aims to explore perceptions of how, why and when doctors and nurses use this method of information recording within acute adult services, examine how they perceive it differs from formal clinical note entries, determine how behaviour would change should this practice be formalised, and gain an understanding of their knowledge of information governance procedures. In addition, an anonymised sample of handover notes will be examined to ascertain the nature and quality of information recorded. The aim will be to develop recommendations for practice improvement, and to submit a further proposal to investigate these issues more widely.