record keeping v1

Record KeepingBy Sharon Leverton

Definition

A health record is defined in section 68(2) Data Protection Act 1998 as:-

• Information relating to the physical or mental health or condition of an identifiable individual.

• Records being made by or on behalf of a health professional in connection with the care of an individual.

Quiz!

Q1. Is your work diary classed as a health care record?A. YES

Q2. As an Health care worker are the records that you create deemed as public records?B. YES

True Or False

Q3. Everyone working for or with the NHS who records, handles, stores or otherwise comes across information has a personal common law duty of confidence.A. TRUE

Q4. The Data Protection Act 1998 now places statutory restrictions on the use of personal information, including health information.A. TRUE

Delegation &Countersigning Standards

• Records created by non registered staff must be countersigned at the end of each episode of care or at least 4 monthly for Level 1 & level 2 patients

• For complex patients the caseload holder retains the responsibility for all delegated tasks

• In these cases the caseload holder should make the decision on the frequency of countersigning

What Are The Benefits Of Good Record Keeping?

• Easier continuity of care• Documentary evidence of services delivered• Communication and sharing of information between

members of the multi-professional healthcare team• Identify risks and enabling early detection of

complications• Supporting clinical audit, research, allocation of

resources & performance planning• helping to address complaints or legal processes

What Makes AGood Health Care Record?

• Factual, Consistent, Accurate• Consecutive & Chronological• Written up as soon as possible• Legible Handwriting• Dated, Timed & Signed• Free of jargon• Non judgemental• Involve patients• Evidence of care planned, care delivered and

information shared

Quotes Taken From Healthcare Records

• “By the time he was admitted, his rapid heart had stopped and he was feeling much better”.

• “Her husband seems surprisingly sensible”.• “Mr X thinks more of his dog than his wife”• “Between you and me, we ought to be able to

get this lady pregnant”.• “The lab test indicated abnormal lover

function”.

How Can You Avoid Similar Mistakes?

• Read back your own records and those of others

• Audit records in line with policies and procedures

What Is The Main Barrier ToMaintaining Accurate Records?

• No paper• Not being able to use a computer• Time• Not knowing what to write• Not being familiar with standardised medical

abbreviations

What Are The Consequences of poor

record keeping?

• Poor patient care• Lack of continuity of care• Mistakes• Complaints• Scrutiny of documentation• Disciplinary procedures• Criminal proceedings• Death

When Things Go Wrong

• Clinical supervision• Notes review• Incident reporting• Governing body support and advice

http://www.nmc-uk.org/Hearings/Hearings-and-outcomes/

http://www.hpc-uk.org/complaints/hearings/

http://www.justice.gov.uk/downloads/burials-and-coroners/guide-charter-coroner.pdf

Remember!

“IF IT IS NOT WRITTEN DOWN, IT WAS NOT DONE”

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Thank you for your time!

Sharon Leverton