Documentation is one of the first things CQC inspectors review when assessing a care service. Yet time and again, providers receive enforcement actions not because of the care they deliver, but because of how they document it.
In this guide, we break down the ten most common documentation mistakes and provide clear, actionable steps to resolve them.
1. Vague or Non-Specific Language
Phrases like "resident was fine" or "had a good day" tell an inspector nothing meaningful. Every note should describe observable, measurable details.
Instead of: "Mrs Jones seemed okay today."
Write: "Mrs Jones ate 75% of her lunch independently, engaged in conversation during the afternoon activity session, and reported no pain during her evening check."
2. Missing Timestamps
Every entry should include a date and time. Without them, it's impossible to establish a timeline of care — which is critical during incident reviews and safeguarding investigations.
3. Task-Focused Rather Than Person-Centred
Notes that read like a checklist ("Given medication. Changed bed. Washed.") miss the human element that CQC inspectors look for. Records should reflect the service user's experience, preferences, and outcomes.
4. Using Abbreviations Without an Agreed List
Abbreviations can cause confusion and misinterpretation. If your service uses abbreviations, maintain a standardised list that all staff can reference. Avoid clinical shorthand that care workers may not understand.
5. Copy-Paste or Identical Entries
When daily records look identical day after day, inspectors flag this as a sign that notes are being written generically rather than reflecting actual care delivered. Each entry should be unique to the day.
6. Retrospective Recording Without Labelling
Writing notes hours or days after the event is sometimes unavoidable, but it should always be clearly labelled as retrospective, with the actual time of the event noted alongside the time of writing.
7. Not Recording Service User Preferences or Refusals
If a service user declines care, this must be documented — including what was offered, why it was declined, what alternative was proposed, and whether the matter was escalated.
8. Gaps in Recording
Missing entries create dangerous blind spots. If nothing is recorded for a shift, it raises questions about whether care was delivered at all. Even quiet shifts should be documented.
9. Not Linking to Care Plans
Daily records should demonstrate that the care being delivered aligns with the person's current care plan. Cross-referencing care plans strengthens your evidence base.
10. Illegible Handwriting or Unsigned Entries
For services still using paper records, every entry must be legible and signed. Digital systems solve this automatically, but the principle remains: accountability is key.
How Evidentia Helps
Evidentia's compliance analysis engine detects many of these issues automatically — flagging vague language, missing specificity, and potential safeguarding gaps before records are finalised.
Disclaimer: Evidentia provides AI-assisted suggestions only. Results should not be treated as professional or regulatory advice. Always verify with qualified professionals.
Evidentia Team
Compliance intelligence insights from the Recordsafe team.