Record keeping Flashcards
Why keep records?
- Aids clinical decision making
- Proof of contact
Define health record
- Consists of data concerning health
- Has been made by or on behalf of a health professional in connection with the diagnosis, care or treatment of the individual to whom the data relates.
Legislation governing record keeping
- Responsibility: Public Records Act 1958 and Local Government Act 1972
- Management and accountability: UK GDPR and Data Protection Act 2018
- Accuracy and completeness: Health and Social Care Act 2008
- In line with professional standards
Clinical reasons for record keeping
- Patient care by team with GP practice, Hospital or Community Pharmacy
- Use of summary care records
- Patient’s EOL wishes
- Care plans
Non clinical reasons for record keeping
- Contractual: Data used for payment of services provided; medicines prescribed (high-cost medication, procedures (surgical)
- Data analysis: Research, clinical trials, risk stratification
- Insurance
- Access:
1. Patients own records via NHS app for repeat prescribing ordering, view blood test results, consultation notes
2. Community pharmacies: Discharge reconciliation, order repeats via online
3. Statutory organisations: Coroner, Professional Bodies
4. Other healthcare professionals
Principles of Record Keeping - CARAT
Clear – legible
Accurate – represent history taken and physical examinations/observations undertaken
Reliable – remain factual
Accessible – format
Timely – up to date (dated)
Signed (by person making entry: name, role)
Risks of Inaccuracies record keeping
Wrong referral : Hip instead of knee replacement – never event
Cancelled operation due to high BP
Missed BT appt due to inaccuracy with booking appt
Inaccurate BT results – wrong bloods ordered or incomplete blood resulting in repeat BT
Mistake with discharge letter leading to incorrect repeat medication
Delay in treatment by OOH due to incorrect SCR
Inaccurately written prescription by OOH resulting in delay in treatment
