record keeping v1
DESCRIPTION
Clinical Skills day 23.1.13 Leicester Peepul centreTRANSCRIPT
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