ABSTRACT
The patient record should clearly state the advice given, the way in which the patient is non-compliant, why the patient is non-compliant if that information is available, details of the risks of such non-compliance and whether the patient has been informed of those risks. If the information from a third person places the patient at risk, the information should not be excluded, but can be dealt with by way of a supplementary record. When the health professional is busy the signature may be rushed and may not resemble the sample. This causes a problem for health professionals who are relying upon those records if they need to contact the writer but cannot recognise the signature. The person who carries out the care and treatment should sign the entry in the record. This includes unregistered staff with first-hand knowledge of the care of the patient.
