Recording concerns and passing them on

Complaint records should be factual, respectful and useful. They should make clear what the patient is unhappy about, what immediate action was taken and who is responsible for the next step.

What useful records include

• The patient's words or main concern, using quotation marks where helpful.
• Dates, times, people or processes involved, if known and relevant.
• Any current health or safety need that required separate action.
• What information was given about the complaints route.
• Who the concern was passed to and when.
• Any follow-up owner, such as complaints lead, manager or clinician.

Keep fact separate from opinion

Do not label the patient as "rude", "difficult" or "always complaining" without a factual description. Describe what was said or done, what was requested, what risk you identified and what action followed.

For example, "Patient said, 'I want the missed call-back looked into'; advised complaints route; prescription query escalated to duty clinician" is clearer and more useful than "patient angry again".

Passing concerns on

Passing a complaint on is not the same as passing gossip. Give enough detail for the complaints lead or manager to act, and use the route your practice has agreed. If the concern involves safety, an incident or safeguarding, use the appropriate reporting route as well.

Confidentiality in Complaints

Good complaint records make it easier to respond fairly and to learn from what happened.