Documentation

The tracheostomy ICP (see Appendix 4) is to be used for all adult patients with a tracheostomy whilst an inpatient at St Georges Hospital (this should be used in conjunction with the early warning score (EWS)) Documentation must be kept in the patient’s bedside folder and updated on each shift. When complete this must be filed in the patients notes. The ICP includes the following sections:

• Record of tracheostomy tube insertion and changes
• Tracheostomy care record
• Tracheostomy equipment checklist
• Tracheostomy weaning plan
• Tracheostomy MDT continuation sheet

Additional documentation such as surgical interventions, limitations on treatment, tracheostomy changes, Speech and Language (SLT) advice, should be clearly documented in the patients’ medical notes.