Clinical Record Keeping Policy

CLINICAL RECORD KEEPING POLICY

Version Date / August 2008
Version Number / 3
Status / Approved
Next Revision Due
EqIA Number / NUR/07/E18 Reassessed August 2008
Developed By / Bev Harris & Lyn Barwick
Policy Sponsor / Head of Professional Development Adult Services
Approved by / Provider Services Clinical Governance Committee
Date approved / Sept 2008

Revision History

Version / Revision Date / Summary of Changers
1 / August 08 / Changes made to roles and responsibilities and monitoring the implementation of the policy.
Changes made to EIRA Assessment

1

TABLE OF CONTENTS

1. Aim 3
2. Background3
3. Clinical Speciality3
4. Organisational Accountability / Responsibilities3
5. Intended Users4
6. Definitions4
7. Indications for Use4
8. Contraindications4
9. Equality and Impact Statement4
10. References 5
11. Context of Policy5

12.Content and Style 5

13. Patient and Client Involvement 6

14. Legal Aspects of Clinical Records 7

14.1 CommunityHospital8

14.2 Community Nursing8

14.3 Health Visiting & School Nursing8

14.4 Allied Health Professionals8

14.5 Dentistry8

14.6 Podiatry8

14.7 Contraception & Sexual Health8

14.8 Learning Disabilities Clinical Teams 8

14.9 Documentation of Controlled Drugs8

15. Patient/Client Held Records9

16. Electronic Clinical Records 9

17. Clinical Audit 9

17.1 Minimum Content of Audit Reports9

17.2 Frequency of Audits 10

17.3 Action Plans 10

17.4 Monitoring and Performance Management of Policy 10

18. Access to Clinical Records 10

18.1Retention of Records 11

18.2 Transportation of Clinical Records 11

19. Support and Additional Contacts 11

Appendix 1 EIRA Assessment

1

1.AIM

It is the aim of this policy to set out the context by whichall clinical records should be completed, and are in line with each of the professional bodies Clinical Records Standards. The policy supports and should be read in conjunction with the Trusts “Records Management Policy”.

2.BACKGROUND

Record keeping is an integral part of a clinician’s clinical practice and duty of care, it is a tool which should aid the care process and should not be seen as separate from this process and is not an optional extra. Whilst records are generally hand written, the clinical record could also include computer records, audio tapes, emails, faxes, video tapes, photographs, compact disc’s and other electronic media.All clinical records regardless of format or type should protect the welfare of the patient/client by

Promoting:-

• High standards of care,
• Continuity,
• Better communication between the inter-professional team involved in the provision of care,
• An accurate account of assessment treatment, care planning and delivery
• The ability to identify risks, and detect problems
• Confidentiality

3CLINICAL SPECIALITY

All adult and children’s services where care is provided by a clinician

4. ORGANISATIONAL ACCOUNTABILITY/ RESPONSIBILITY

The Chief Executive has overall responsibility for the management of clinical records within the Trust.

The Director of Quality & Nursing has been delegated the responsibility of clinical records management by the Chief Executive.

Head of Service have the responsibility of ensuring that all their staff have received training in the relevant aspects of clinical record keeping and that they are compliant with the Clinical Record Keeping Policy.

All health care professionals have a legal duty of care and are responsible for any records that they create or use in relation to patient/client care, this responsibility is established and defined by law.

Where a health care professional is aware (or could reasonably be expected to be aware) that there is an increased possibility / risk of error (caused by temporary or permanent individual circumstances) in recording, filing or retrieving patient records, this must be raised with the individual’s manager. This will then enable a risk assessment (or other appropriate action) to be carried out, with the aim of identifying required actions to remove or minimise the risks.

The policy sponsor for this document is the Head of Professional Development Community services (Adults) and as Chair of the Derbyshire Community Health Services Clinical Committee is also responsible for ensuring that the audit of clinical records is undertaken annually

5.INTENDED USERS

All clinical staff providing care

6.DEFINITIONS

There is no actual definition of a Clinical Record, therefore this has been broken down into “Clinical” & “Record”.

Clinical: Relating to observation and the treatment of patients

Record: Register set down for remembrance or reference, which is in permanent form, and provides evidence of information.

7.INDICATIONS FOR USE

All patients/clients admitted into the Trust for clinical care/treatment

8.CONTRAINDICATIONS

None

9. EQUALITY IMPACT STATEMENT

We welcome feedback on this policy /procedure / strategy and the way it operates. We are interested to know of any possible or actual adverse impact that this policy / procedure may have on any groups in respect of gender or martial status, race, disability, sexual orientation, religion or belief, age, deprivation or other characteristics’.

The person responsible for equality impact assessment for this policy / procedure / strategy is Bev Harris, Head of Professional Development.

This policy has been screened to determine equality relevance for the following equality dimensions:

• Age
• Disability
• Gender
• Race
• Religion/Belief
• Sexual Orientation
• Transgender/Transexual

The policy is considered to be particularly equality relevant for the dimensions of: disability, race and, in some circumstances, age. The equality relevance is considered to be high. A full impact assessment will be conducted by June 2009. The initial impact assessment screening is included at Appendix 1 of this policy.

10.REFERENCES

CSP 2005 Core Standards of Physiotherapy Practice

Data Protection Act 1998

DCPCT Access to Health Records Policy

DCPCT Approved List of Abbreviations

DCPCT Audit Timetable

DCPCT Confidentiality Code of Conduct

DCPCT Information Governance Policy

DCPCT Records Management Policy

DCPCT Preservation, Retention & Destruction Policy

DCPCT Transportation of Records Policy

DH 1997 Caldicott Report

DH 2006 Records Management: Code of Practice Parts 1& 2

DH 2004 Standards for Better Health Care

Freedom of Information Act 2000

GMC 2006 Good Medical Practice

HPC 2008 Standards of Conduct, Performance and ethics

Mental Health Care Commission Standards 2004

NMC 2008 The Code: Standards of Conduct, Performance and ethics for Nurses and Midwives

NMC 2007 Record keeping: A-Z advice Sheet

PCT Information Governance Policy

PCT Confidentiality Policy

PCT Mental Capacity Act Policy

11.CONTEXT OF POLICY

The best clinical record is the product of consultation and discussion between all members of the inter-professional health care team and the patient/client, and carers/relatives/advocates. The record must be evaluated and amended in response to the needs of the patient/client. The record should enable any member of the health care team to care for the patient/client regardless of where they are within the care process or care environment. In line with the Single Assessment process (SAP) the record is required to promote communication between those individuals involved in the provision of care and with the patient/client, their carers/relatives/advocates and reduce unnecessary duplication of assessments

12.CONTENT & STYLE

There are several factors that contribute to effective record keeping, all records should be commenced at the time of the initial contact and be:

• Factual, consistent, accurate and recorded in a way that is clear and meaningful.
• Recorded as soon as possible after the event, providing current information on the intervention, and the condition of the patient/client.
• Legible, concise, and in such a manner that the text cannot be erased or deleted without a record of change.
• The record should be sequential and be recorded in such a manner that any justifiable alterations or additions are dated, timed and signed clearly, all entries should be attributed to a named individual, in an identifiable role in such a way that the original entry can still be read.
• Any necessary deletion due to an error should be made with a single line striking through the relevant error in such a way that the error remains legible. Correction fluid should not be used
• Each entry must be dated timed and signed including errors or amendments.
• Entries made by students should be countersigned by their supervisor/mentor
• Only abbreviations from the PCT approved list should be used, the record should use where possible terminology that is understandable for both carers patients and professionals. The record should not contain meaningless phrases, irrelevant speculation, offensive or subjective statements.
• References to third parties unless significant to the patient/clients care should not be used.
• The record should be readable when photocopied or scanned.

All records must include two patient identifiers: the patient’s name, and NHS Number. These should be recorded on each separate page/sheet within the record. All records where patients are being cared for in a clinic/hospital/ward environment must also include the name of the hospital and ward/department

In addition the record should:-

• Be recorded where possible with patient/client, carer/relative/advocate involvement.
• Be recorded in terms that the patient/client, carer/relative/advocate can understand
• Identify risks and or problems, variances from the care plan, that have arisen and the interventions made to rectify this
• Provide clear evidence of the care planned as a result of the assessment, the decisions made, care delivered, the information shared and with whom.

13.PATIENT& CLIENT INVOLVEMENT

Patients and clients should be equal partners in the assessment and decision making process of their care and the compilation of theclinical record. Where patients do not have the mental capacity to be involved in this process then staff should refer to the Trust Mental Capacity Policy. Staff should also take into consideration the Data Protection Act 1998:the Access Modification (Health) Order 1987 and the Access to Health Care Records Act 1990. Procedures for access must be in accordance with the Freedom of Information Act 2002.

In some cases registered clinical staff can withhold information if they feel that in their professional judgement the provision of information may cause serious harm to the patient/clients physical or mental health or would breech the confidentiality of another patient/client. Registered clinical staff who make such decisions must be able to justify the reasons for withholding information and ensure a record for this has been made.

Some patients and/or their carers / relatives / advocates may have more difficulty than others in communicating and understanding matters relating to their medical records. Consequently, staff involved in the policy’s implementation will need to proactively consider the additional actions that might be required to ensure that the requirements of all patient groups can be met as far as is practicably possible when: involving and communicating with patients and other relevant parties.

14.LEGAL ASPECTS of CLINICAL RECORDS

Registered clinical staff have both a professional and legal duty of care in line with clinical governance and patient safety, and must ensure that their records give a full account of their:

• Assessment
• Care planned and provided
• Relevant information about the condition of the patient/client at any given time
• That all reasonable steps have been taken to care for the patient,
• That any actions or omissions on the part of the registered professional have not compromised the safety of the patient/client in any way.

Where patients meet the Continuing Care Criteria evidence of the decision making process must be recorded with in the clinical record.

Registered clinical staff who are working with patients/clients, who are subject to mental health legislation, must ensure that they have a thorough working knowledge of the statutory powers as they apply to their particular area of practice. When making entries into clinical records for these patients/clients they must comply with guidance given by the Mental Health Act Commission for England 2004.

Registered clinical staffwho are professionally accountable for ensuring that any duties they delegate to members of the multi-professional team who are not registered with a professional body are undertaken to a reasonable standard. For instance if a registrant delegates work which requires a student or Health Care Assistant to make a record in the patients clinical record they must ensure they have the necessary knowledge and skills to undertake this aspect of care. Where the student or Health Care Assistant has not been assessed as being competent to undertake record keeping then the registrant must countersign the entry in the clinical record. Registrants remain professionally accountable for the appropriateness of the delegation and the actions or omissions of the student or health care assistant.

Registered clinical staff are required to use their professional judgement in deciding what is relevant to record within the patient/clients record; this applies particularly to situations where the patient/clients condition is unchanging. In these circumstances the Trust requires any registrants to ensure an entry is made in the record at a minimum of:

14.1COMMUNITYHOSPITAL:

Entries made in the multidisciplinary patient record must reflect all care delivered by any member of the multidisciplinary team within a 24 hour period. Treatment plans must be evaluated and reviewed and recorded as changes occur but at least once a week as a minimum.

14.2COMMUNITY NURSING:

Monthly for each care problem, but this will be dependent on the acuity of the problem and may be weekly, daily, or more frequent as the patients condition dictates. For patients whose care is being evaluated and reviewed for continence problems or B12 therapy then a record should be made six monthly minimum.

14.3HEALTH VISITING & SCHOOL NURSING

Every face to face contact and significant telephone contact.

Significant information in relation to other services that contribute to the care of the client should also be required.

14.4 Allied Health Professionals

At each Contact.

14.5 Dentistry

At each Contact.

14.6 PodiatryOptometrist

At each Contact.

14.7 Contraception & Sexual Health

At each Contact.

14.8 LEARNING DISABILITY CLINICAL TEAMS

• Community staff record every face to face contact and telephone contact.
• In-patient area staff record daily during admission.
• Hand held Health Action Plans in accessible information format are developed for each individual who wishes to hold one.
• Supplementary to the Health Action Plans are Health Surveillance Records which are filed in nursing notes.

Registered clinical staff must remember that in a court of law the approach taken is that “if it is not written down it has probably not been done”, and this will be the approach taken within the Trust: when records are used for the purposes of clinical audit, and investigations into complaints and incidents.

14.9DOCUMENTATION OF CONTROLLED DRUGS

Please refer to the Trusts Medicine Code.

15PATIENT/CLIENT HELD RECORD

With the introduction of the Single Assessment Process (SAP) and the Patient/Parent Held record (PHR), many patientshold their own records and this should be encouraged where possible. Patients/clients should be informed of the purpose and importance of the record and their responsibility for keeping it safe, a record of the discussion and the advice given should also be made in the clinical record.

Registered clinical staff may need to keep supplementary records to which access by the patient/ client is limited or withheld, in such cases this should not extend to keeping a full duplicate of records and should be the exception rather than the norm. In such circumstances registrants should be able to justify the keeping of a supplementary record and its existence must be made clear to all the health care team involved in the care/treatment of the patient/client.

Within Child & Family services the Trust Child Health Records is the only clinical record that is maintained by health professionals. No other supplementary record should be raised.

16.ELECTRONIC CLINICAL RECORDS

Where electronic records are kept there is no requirement to keep duplicatepaper based clinical records. All record keeping using whatever medium should take account of the need to maintain communication between the multi-professional health care team providing care/treatment for the patient/client. Staff should refer to the Trust Information Governance Policy.

The principle of confidentiality is equally important when electronic clinical records are being used including those sent by fax/email and should comply with the Trust’s Information Governance policy. Registered clinical staff are professionally responsible for making sure that whatever system they use is fully secured and managed in such a way that confidentiality is maintained.

Registered clinical staff are accountable for any entry made with in the electronic record and must ensure that any entry made is easily identifiable. Shared passwords are unacceptable and should never be used, please refer to the IM & T Security Policy

17.CLINICAL AUDIT

Clinical audit is one component of risk management and the improvement of clinical standards and applies equally to the process of clinical record keeping. By auditing the record registrants are able to assess the standard of record keeping and identify areas of improvement and staff development. The criteria against which clinical records must be audited are those identified in the Content and Style section of this policy.

17.1MINIMUM CONTENT OF AUDIT REPORTS

The minimum content of clinical records will be audited using the PCTs standardised Clinical Records Audit Tool. Results of audit will be reported on using the Standardised Clinical Audit Reporting Template. The audit tool and reporting template can be found on the Trusts Intranet.

17.2FREQUENCY OF AUDITS

All registrants are required to participate in undertaking audit of clinical records according to their Dept/Ward/Teams respective annual clinical audit plans. Staff should refer to the Trust’s Clinical Audit Committee for advice/support where appropriate. The percentage of clinical records audited and frequency should be identified clearly in the respective service/s annual clinical audit plan, as a minimum clinical records audit should be taken annually.

17.3ACTION PLANS

Action plans will be developed as a result of the Clinical audits and will be presentedtothe relevant Governance Committees within the trust. Actions from this will be cascaded to the appropriate areas for implementation with progress reported back the Governance Committees on a regular basis.