Documentation for a travel health consultation

Why is good documentation important in a travel health consultation?

Documentation is essential to provide safe practice by ensuring that the consultation is recorded with the specific advice given to the patient. Instead of writing ‘advice given’ try to be more specific.

It is vital that adequate and appropriate information is recorded and is in accordance with the Data Protection Act. The reason for data storage should be understood by the practitioner. For example; if there is a recall on a vaccine batch number, a request for a duplicate yellow fever certificate or an adverse event.

Good documentation enables someone else taking over future consultations to know exactly what advice the patient has been given, the management plan for the course of vaccines and where to access the travel risk assessment form and any other information. It is easy to assume that another clinician has done something – documentation can confirm or refute this.

The RCSPG (2023) advises that the system for recording should be robust, confidential and fit for purpose.

The clinical record should demonstrate that:

• An appropriate and thorough pre-travel risk assessment has been performed

• Risks have been identified and an appropriate management plan proposed and advice given

• Informed consent was given prior to vaccination

• Which vaccines were offered and supplied, including specific details as stated in the National Minimum Standards and Core Curriculum for Immunisation Training for Registered Healthcare Practitioners (PHE 2018) and if Group Directions are used

• Where required, what malaria prevention advice was provided and what chemoprophylactic medicines were supplied or advised

• What general travel advice was given;- as a minimum this should include advice on accidents, individual personal medical problems and associated medication, issues of personal safety and security, environmental considerations, infectious disease risks and any risk-behaviour modification

• What written information was provided to the traveller. Any information regarding vaccines administered and malaria chemoprophylaxis

• Where advice/vaccinations offered were rejected, the reasons why and any additional advice given as a result