2.10 Outline the principles of record keeping in advance care planning

This guide will help you answer 2.10 Outline the principles of record keeping in advance care planning.

Advance care planning involves discussing and documenting an individual’s wishes for their future care. The aim is to make sure that, if the person cannot express their views later, their preferences are still respected. Record keeping is a key part of this process. Without clear, accurate, and accessible records, the plan can be lost, misunderstood, or ignored.

Good record keeping supports quality care. It ensures that everyone involved is working from the same agreed information. In health and social care, records are both a communication tool and a legal requirement.

In this guide, we will focus on the principles that guide record keeping in advance care planning. These principles apply whether records are paper-based or electronic.

Accuracy and Clarity

Advance care plans must be recorded accurately. This means writing down the information exactly as the person has expressed it, without adding personal opinions or assumptions.

Clarity means that the record should be easy to read and understand. Avoid jargon or abbreviations that others might not recognise. If specialist terms are needed, explain them in plain language.

Accurate and clear records prevent errors in care. They allow professionals to follow the person’s wishes with confidence.

Points to consider for accuracy and clarity:

• Record what was said, not what you think was meant
• Check spellings of names, medications, and places
• Use clear, straightforward language
• Keep sentences short
• Avoid slang or regional expressions that may confuse someone outside the local area

Timeliness

Records should be written as soon as possible after the discussion or decision takes place. This reduces the risk of forgetting key details or mixing up information.

In some cases, delays in recording can lead to mistakes in care. For example, if a person changes their mind about a treatment option, but the update is not recorded promptly, old information might be followed.

Timely recording is particularly important in advance care planning because decisions may need to be acted upon quickly in emergencies.

To maintain timeliness:

• Document during or immediately after the meeting
• Date and time every entry
• Notify relevant staff that the record has been updated

Consistency

Records need to be consistent across all formats and systems. If the information on paper does not match what is stored electronically, confusion will occur. This could be dangerous in urgent situations when quick decisions are needed.

Consistency makes the plan reliable, as it ensures the same directions appear in all copies of the record.

Steps for consistency:

• Update all versions of the record at the same time
• Use the same wording in different copies
• Make sure signatures, dates, and approvals match

Confidentiality

Advance care plans often contain sensitive personal information. This can include details about medical conditions, religious or cultural wishes, and personal values.

Keeping this information confidential is a legal and ethical obligation. In the UK, this is protected under the Data Protection Act 2018 and supported by the UK GDPR rules.

Only people involved in the person’s care should have access to the plan. Sensitive conversations should take place in private settings.

To protect confidentiality:

• Store records securely, whether physical or digital
• Limit access to authorised staff
• Avoid discussing private details in public or open areas
• Use locked cabinets for paper records and password protection for digital files

Comprehensiveness

A record in advance care planning should be complete. It should capture all the relevant points discussed, including the context behind choices. This may involve recording the person’s reasoning for a decision.

A comprehensive record:

• Reduces the risk of misunderstandings
• Gives a clear picture for those who were not part of the original discussion
• Supports legal protection in case of disputes

Information to include may be:

• Personal details of the person
• Date of the discussion
• Names of all those present
• The individual’s preferences and wishes
• Specific treatments they wish to accept or refuse
• Cultural, spiritual, or family factors
• Signatures from the person and witnesses

Legibility

If records are handwritten, legibility is critical. Poor handwriting can lead to dangerous errors, especially in healthcare settings.

If typed, ensure the text is clear and well-structured. Use headings, bullet points, and spacing to make the record easy to navigate.

Tips for legible records:

• Use black or blue ink for lasting clarity
• Avoid writing in all capital letters
• Keep lines of text neat and evenly spaced
• For digital records, use standard fonts of a readable size

Accessibility

An advance care plan must be accessible to those who need it. In an emergency, there is no time to search through multiple systems or request access from another department.

Accessibility does not mean open access to everyone. It means that authorised staff can get the record quickly when needed.

Ways to improve accessibility:

• Store the record in a known, designated place
• Make sure colleagues are aware of where it is kept
• Use shared systems that are secure but quick to search
• Provide a summary sheet in the care file for instant reference

Respect for the Individual’s Voice

The record should reflect the person’s own words and style where possible. This supports their right to self-determination in healthcare decisions. It should avoid sounding like a medical directive unless that is the person’s choice.

Recording in their own voice can help others understand the motivations behind the decisions.

Examples:

• “I do not want to be admitted to hospital for respiratory problems” rather than a generic “No hospital admission”
• “I would like my dog to be allowed to visit me” instead of just noting “Pets allowed”

Objectivity

Record keeping must remain factual and unbiased. Staff should avoid making personal comments about the individual’s choices. A care worker’s role is to record what was agreed, not to persuade or criticise.

To stay objective:

• Separate facts from opinions
• Avoid emotional language
• Do not speculate on why someone made a decision unless they explained it and you are including their explanation

Legal Requirements

Advance care planning records can have legal standing. They may be referred to in cases where care decisions are challenged. For this reason, they must meet legal standards and follow care sector regulations.

In the UK, specific legal frameworks can apply:

• The Mental Capacity Act 2005, which covers advance decisions to refuse treatment
• Human Rights Act 1998, which supports the right to privacy and respect for personal choices
• Data Protection Act 2018, which governs how records are stored and shared

Following these laws is part of professional responsibility in health and social care.

Consent

Recording a person’s wishes for future care requires their consent. This consent must be obtained before the discussion and confirmed again when the record is shared or stored.

For people who may lack capacity, their legal representatives or appointed decision-makers must be involved.

To demonstrate consent in records:

• Clearly note that the person agreed to the discussion and the recording of their wishes
• Record any documents signed, such as consent forms or advance decision letters
• Include details of who else was present and their relationship to the individual

Updating and Reviewing Records

People’s wishes can change over time as their health, personal circumstances, or values change. A good system for record keeping should include regular reviews.

Out-of-date records can cause distress if they are followed in place of more recent wishes.

To maintain accuracy:

• Agree review dates in advance with the person
• Update records immediately after any change
• Mark old versions clearly as ‘superseded’ to avoid confusion

Version Control

Version control means keeping track of changes made to a record over time. This helps to avoid mixing up earlier and updated plans.

Good version control practices:

• Number each version of the document
• Keep a record of changes and who made them
• Use date stamps for all entries

In electronic systems, version control may be built in, but paper-based records must be managed manually.

Professional Standards

Staff recording advance care plans must follow organisational policies and professional codes of conduct. This ensures records meet quality and ethical standards.

Training is an important part of this process. Staff should know how to:

• Use approved forms and templates
• Follow correct data protection procedures
• Communicate respectfully and sensitively during discussions

Communication Between Services

Advance care planning often spans multiple services — hospitals, GPs, hospices, home care. For plans to be effective, the record must be shareable in a secure way.

To support communication:

• Use agreed formats recognised by different services
• Avoid storage in isolated systems that others cannot access
• Include contact details for follow-up questions

Cultural Sensitivity

Records should reflect cultural factors that influence care choices. These may affect end-of-life care preferences, religious considerations, or the involvement of family.

Being culturally sensitive in record keeping means:

• Using the individual’s own terms for cultural practices
• Avoiding stereotypes
• Recording precise instructions for cultural or religious needs

Final Thoughts

Good record keeping in advance care planning supports respect, dignity, and person-centred care. The principles explained above focus on fairness, accuracy, and respect for individual wishes. They also help protect health and social care workers, providing a clear record of what was agreed and when.

In practice, record keeping is as much about communication as it is about documents. The way information is gathered, recorded, stored, and shared determines whether an advance care plan will be honoured. By following these principles, you help to make sure the individual’s voice remains present in every care decision, even if they cannot speak for themselves.