Document should be filed in:

Minimum Standards for

Clinical and Practice Records

Clinical Standard

See also: / In folder:
Service Area / Issue Date / Issue
No. / Review Date
All Clinical Areas in DCHS / Jan 2010 / 4 / Dec 2010
Author(s): / Ratified by: / Responsibility for
review:
Roger Simpson, Eileen Carter / Clinical Records Committee (TBC) / Lyn Barwick (TBC)

Draft Revision 4 Jan 09 Page 1 of 15

Minimum Standards for Clinical and Practice Records

Standard 1

Clinical and practice records (however recorded) contributing to the care of the patient to be accessible to clinical and practice staff involved in the care of the patient

Standard 2

Clinical and practice records (however recorded) contributing to the care of the patient to be accessible to patients as appropriate to their circumstances

Standard 3

Clinical and practice records to contain a complete set of identification data

Standard 4

Clinical and practice records to be contemporaneous, up-to-date and chronological

Standard 5

Clinical and practice records to be legible

Standard 6

All entries in clinical and practice records to be dated, timed, and signed

Standard 7

Clinical and practice records to be maintained in such a way that enhances accuracy

Standard 8

The clinical and practice record to (a) contain all relevant clinical information, (b) be of high quality, and (c) be complete

Standard 9

The clinical and practice record to include clear evidence of all patient and carer a) involvement and b) consent to care

Standard 10

The clinical and practice record to contain discharge/transfer/leave information

Appendix 1

CommunityHospital Essential Clinical Information for Standard 8

a)Assessments (including Risk Assessment/Examinations) with dates in an action plan, and rationale/formulation.(9)

b)Allergies and reactions to be recorded as part of the assessment for each patient episode, and to be immediately identifiable within the record. This may include food, cosmetics, pollen etc.

c)Details of any discussions/decisions made regarding the management of risk.

d)A social and family history

e)A record of the persons appearance

f)Care Plan (including Treatment/Intervention) This must relate to the most recent MDT assessment/Review (9)

g)A clear concise record of all care given, including any variances in planned care or implementation of the treatment plan(9)

h)Review/evaluation of outcome/follow-up/progress(9)

i)History of physical/mental illness

Appendix 2

Community Nursing Essential Clinical Information for Standard 8

a)Assessments (including Risk Assessment/Examinations) with dates in an action plan, and rationale/formulation.

b)Allergies and reactions to be recorded as part of the assessment for each patient episode, and to be immediately identifiable within the record. This may include food, cosmetics, pollen etc.

c)Details of any discussions/decisions made regarding the management of risk.

d)A social and family history

e)Care Plan (including Treatment/Intervention) This must relate to the most recent assessment/review

f)A clear concise record of all care given, including any variances in planned care or implementation of the treatment plan

g)Review/evaluation of outcome/follow-up/progress

h)History of physical/mental illness

Appendix 3

Children and Young Peoples Essential Clinical Information for Standard 8

a)Rational for contact and any “transfer in”/handoverinformation.

b)Health Needs Assessments (including Risk Assessment/Examinations/Results of Tests) and summary of needs and issues still to be addressed.

c)A social and family history.

d)Plan of care/intervention delivered by all practitioners that relates to the most recent assessment/review.

e)A clear concise record of all care given, including any variances in planned care or implementation of the plan of care/intervention.

f)Review/evaluation of outcome/follow-up/progress

References for the Clinical Records Standards

Updated Jan 2010

General References requiring a Clinical Records Audit

  1. NHSLA Risk Management Standards for Acute Trusts, Primary Care Trusts and Independent Sector Providers of NHS Care (Version 2), NHS Litigation Authority, February 2009
  1. Records Management: NHS Code of Practice Part 1, Department of Health, March 2006
  1. Records Management: NHS Code of Practice Part 2 (2nd Edition), Department of Health, January 2009
  1. Essence of Care: Patient-focussed benchmarks for clinical governance, NHS Modernisation Agency, April 2003
  1. National Standards, Local Action, Health and Social Care Standards and Planning Framework 2005/06–2007/08, Department of Health, July 2004

Specific References re the contents of Clinical Records

  1. Clinical Record Keeping Policy (Version 3), Derbyshire CountyPCT, August 2008
  1. Policy for Consent to Examination or Treatment (Version1), Derbyshire CountyPCT, February 2008
  1. Mental Capacity Act Policy (Version 2), Derbyshire County PCT, June 2007
  1. Record keeping: Guidance for nurses and midwives, Nursing and Midwifery Council, July 2009
  1. NHS Number Programme Implementation Guidance, NHS Connecting for Health, December 2008
  1. Positive and Inclusive? Effective4 ways for professionals to involve cares in information sharing, National Co-ordinating Centre for NHS Service Delivery and Organisation R&D, Autumn 2004
  1. Information Sharing and Mental Health, Guidance to Support Information Sharing by Mental Health Services, Department of Health, August 2009

Draft Revision 4 Jan 09 Page 1 of 15