A GUIDE TO GOOD RECORD KEEPING
GINA KELLY, TRUST HEALTH RECORDS MANAGER
TO OBTAIN A COPY OF THIS BOOKLET IN LARGER PRINT, PLEASE CONTACT GINA KELLY
Telephone: 0151 471 2351
Welcome to Mersey Care NHS Trust’s
Guide to good record keeping.
This is a brief overview of how Mersey Care NHS Trust expects you as a health practitioner to understand our processes when writing clinical records whilst working on behalf of the Trust.
Further information is available on our website www.merseycare.nhs.uk Select working for us, Corporate Health Records Policies and Procedures on health records IT06.
A GUIDE TO GOOD RECORD KEEPING
CONTENTS Page
Definition of a Health Record? 4
Who’s Responsible for Health Records 4
Why are Records valuable 5
Why good record keeping is important 5
What is considered good practice 6
Health Records -National Standards and
Mersey Care NHS Trust Standards 7
Contemporaneous Notes 9
Reminders 9
Protecting Health Records 11
Tips to help Clinical Staff 12
Common Law Duty & Confidentiality 13
Caldicott – Background & Principles 14
The Data Protection Act – Principles 17
Further information 20
A GUIDE TO GOOD RECORD KEEPING
Definition of a Health Record
“A single record with a unique identifier containing information relating to the physical or mental health of a given service user who can be identified from that information and which has been recorded by, or on behalf of, a health professional, in connection with the care of that patient. This may comprise text, sound, image and/or paper and must contain sufficient information to support the diagnosis, justify the treatment and facilitate the ongoing care of the patient to whom it refers.”
Department of Health, Records Management – NHS Code of Practice Part I
WHO’S RESPONSIBLE?
All staff are responsible for any records, which they create or use.
Everyone working for or with the NHS who records, handles, stores or otherwise comes across patient information has a personal common law duty of confidence to service users and to his/her employer. The duty of confidence continues even after the death of the service user or after an employee or contractor has left the NHS.
Personal information (e.g. about a service user) processed/kept for any purpose should not be kept for longer than is necessary for that purpose. Service user information may not be passed on to others without the patient’s consent except as permitted under Schedule 2 and 3 of the Data Protection Act 1998 or, where applicable, under the common law where there is an overriding public interest.
WHY ARE RECORDS VALUABLE?
· Records are valuable because of the information they contain and that information is only usable if it is correctly and legibly recorded in the first place, is then kept up to date, and is easily accessible when needed.
If it is not recorded it did not happen.
· A Health Record may be called as evidence in legal proceedings or a professional misconduct hearing.
· The Data Protection Act 1998 gives individuals the right to Access Their Health Records held manually or on computer.
WHY GOOD RECORD KEEPING IS IMPORTANT
You can work with maximum efficiency without having to waste time hunting for information.
There is an “Audit Trail” which enables any record entry to be traced to a named individual at a given Date/Time with the secure knowledge that all alterations can be similarly traced.
Those coming after you can see what has been done, or not done, and why.
Any decisions made can be justified or reconsidered at a later date.
Everyone who records service user’s information should be aware that records are also kept because one day they may be needed:-
· By the service user applying to have access to their own health records under the Data Protection Act.
· By the service user’s solicitor for a third party litigation claim
· By the service user’s solicitor for a clinical negligence claim against the Trust
· By the service user’s solicitor in support of a clinical negligence claim against another Trust
· By you to write a report for a litigation claim
· By you to write a report for a clinical negligence claim
· By you to demonstrate that you have not been professionally negligent in any way
· By you to protect your job
· By the Trust for managing complaints
· By the Trust for managing audits
· By the Trust for managing issues of the Data Protection Act
· By the Trust for managing research
WHAT IS CONSIDERED GOOD PRACTICE ?
· Make comprehensive notes of actions and outcomes.
· Detail all complex problems, or where more input has been required.
· Show duty of care has been honoured.
· Think about what you write, humour does not fare well in the legal arena.
· Take care when recording information regarding or given by a third party, clearly state that the information has been given by a third party and mark it.
· Document clearly when discussion has taken place with a Senior Team Member.
· Record all information; it may be crucial if a complaint is made.
· Ensure the information you record is really relevant
· Make sure you read what you have written – Does it make sense!!
NATIONAL STANDARDS AND STANDARDS WITHIN MERSEY CARE NHS TRUST
Service user and client records should:
· Be factual, consistent and accurate
· Be input/scanned (if electronic Health Record) / written (if manual Health Record) as soon as is practicably possible after an event has occurred, providing current information on the care and condition of the service user – if the date and time differs from that of when the records are written up this should be clearly noted in the record – NB audit trails are performed on electronic entries made into Health Records.
· Be written clearly, legibly and in such a manner they cannot be erased.
· Be accurately dated, timed and signed with the signature being printed alongside the first entry
· The use of abbreviations should be kept to a minimum.
· Be written, wherever possible, with the involvement of the service user or carer and in terms that the service user or carer will be able to understand.
· For those few areas where it is still required to use manual Health Records
· Entries written into paper based records should be written in black ink.
· Be consecutive.
· Erasers, liquid paper, or any other obliterating agents should not be used to cancel errors. A single line should be used to cross out and cancel mistakes or errors and this should be signed and dated by the person who has made the amendment.
· Be bound and stored so that loss of documentation is minimised.
Be relevant and useful
· Identify problems that have arisen and the action taken to rectify them.
· Provide evidence of the care planned, the decisions made, the care delivered and the information shared.
· Provide evidence of actions agreed with the service user (including consent to treatment and/or consent to share).
And include
· Clinical observations: examinations, tests, diagnoses, prognoses, prescriptions, other treatments.
· Relevant disclosures by the service user – pertinent to understanding cause or effecting cure/treatment.
· Facts presented to the service user.
· Correspondence from the service user or other parties.
Service user records should not include
· Unnecessary abbreviations, jargon, meaningless phrases, irrelevant speculation and offensive subject statements
· Personal opinions regarding the service user (restrict to professional judgements on clinical matters)
· The name(s) of third parties involved in a serious incident. The name should be included on the separate incident form for cross referencing.
· Entries written in the style of text language, e.g. “l8r”.
· Correspondence generated from legal papers and complaints.
Contemporaneous notes
Information recorded about the service user should be written at the time of the event, or as soon afterwards that is practicably possible, to provide a chronological and accurate record of events. This is vitally important as it captures the reality of the events within which the service user’s care was delivered and can be used in any legal proceedings. It is important that healthcare professionals ensure that contemporaneous notes are made at the time of the service user’s consultation and reflect the care given or omitted and the rationale for these decisions.
REMEMBER!!!
You are responsible for what you write!
If it isn’t recorded then there is no proof that something has been done.
Clients have the right of access to their own Health Records under the Data Protection Act 1998 however, this is by formal application only. Further information on page 17.
Health Records can be produced as evidence in legal proceedings or misconduct proceedings.
You have a duty of confidence to ensure that any person identifiable information is only given to authorised staff and that information divulged to an unauthorised person can result in dismissal.
If you are handling health records you are responsible for ensuring their safe-keeping whilst they are in your care.
PROTECTING HEALTH RECORDS AND THE INFORMATION THEY CONTAIN AGAINST LOSS, DAMAGE OR UNAUTHORISED ACCESS
The confidential nature of Health Records cannot be overstressed and must always be borne in mind by those who have to handle such records. Authorised staff will be given access to computer systems via the application of a User Identifier. Individual staff must be responsible for the security and maintenance of their own individual password. Audit trails can then be performed on data access within the system.
Health Records must not be left in a position where service users, or unauthorised persons can obtain access to them, whether they are on computer screens or any other format e.g. in hard copy. It is also essential that the individuals involved in handling the Health Records are responsible for ensuring that the Health Record is safeguarded against loss, damage or use by unauthorised persons.
Information contained within the Health Record must not be revealed to any unauthorised persons.
SCANNING OF DOCUMENTATION INTO ELECTRONIC HEALTH RECORDS
Any document, relevant to the care and treatment of a service user, that would previously have been filed into a manual Health Record should be put into the electronic Health Record using locally based scanners.
Staff who have the responsibility for scanning documentation onto the clinical systems must ensure they do this as soon as is practicably possible in a timely manner so that this information is readily accessible.
Any documentation scanned into the electronic Health Record held on WinDIP, should contain the unique identifier which must be cross referenced with electronic Clinical Information System e.g. Epex/PACIS.
HANDY TIPS TO HELP CLINICAL STAFF
· Make Friends with: Secretaries, Health Records Staff, Ward Clerks, Receptionist and out patients clerks – they will guide you through the relevant system.
· Discharge letters – They have to be done – and you can’t change that fact DO THEM so they don’t prey on your mind and build up.
· TTO Forms – Must be completed upon service user’s Discharge – G.P.’s must be sent out a copy within 2 days of discharge.
· CPA Documentation – When dictating letters always make reference to:
The service users’s CPA level (standard or enhanced)
The name and contact number of the keyworker.
Where the service user is identified as on enhanced CPA ensure CPA form has been completed and sent to appropriate people.
CONFIDENTIALITY
In all walks of life any personal information given or received in confidence for one purpose may not be used for a different purpose or passed to anyone else without the consent of the provider of the information. This duty of confidence is established in the NHS may lead to disadvantages to the patients or to that of the public in general.
The Health Service collects and holds large volumes of confidential information about you, members of your family, friends and colleagues, although the vast majority of this information will be about strangers, most of whom you are unlikely to meet. The information we hold belongs to them and we merely act as custodians. Their information should be afforded as much respect and integrity as you would expect yourself. Handle their information with care. It is your responsibility to protect that information from inappropriate disclosure and to take every measure to ensure that personal identifiable information is not made available to unauthorised persons. These principles apply equally to data about staff as well as patients.
BACKGROUND TO CALDICOTT
Why Caldicott?
A Committee, Chaired by Dame Fiona Caldicott, was set up by the Chief Medical Officer for Health following increasing concerns regarding the flow of information within the NHS, but also to and from organisations outside the NHS. The resultant report “The Caldicott Committee: Report on the Review of Patient-Identifiable Information”, was published in 1997. A further review took place in 2012 and a new report “Information: To share or not to share? The Information Governance Review” was published in 2013.
What is a Caldicott Guardian?
A senior health professional or existing member of the Trust Board who is responsible for reviewing and agreeing protocols governing the disclosure of personal information about the patients across organisational boundaries.
Who is the Caldicott Guardian?
The Caldicott Guardian for Mersey Care NHS Trust is: Dr. David Fearnley
What did the Caldicott Committee do?
The Committee produced a set of six general principals for the safe handling of patient identifiable information. These principles work hand-in-hand with the Data Protection Act 1998 and must be adhered to when collecting, transferring, or generally working with personal information. The six principles are as follows:
1. Justify the purpose
Every proposed use or transfer of patient-identifiable information within or from another organisation should be clearly defined (and reviewed regularly).
2. Do not use patient-identifiable information unless it is absolutely necessary.
Patient-identifiable information should not be used unless there is no alternative.
3. Use the minimum necessary patient-identifiable information
Where use of patient identifiers is considered to be essential, each individual item of information should be justified with the aim of reducing identification.
4. Access to patient-identifiable information should be on a strict need to know basis
Only those individuals who need access to patient-identifiable information should have access to it.
5. Everyone should be aware of their responsibilities
Action should be taken to ensure that all staff are aware of their responsibilities and obligations in respect of patient confidentiality.
6. Understand and comply with the law
Every use of patient-identifiable information must be lawful