Policy on the completion of case records

Key principles:

Records should be completed at the time or as soon as possible after the event.
All records must be signed, timed and dated if handwritten. If digital, they must be traceable to the person who provided the care that is being documented.
Ensure that you are up to date in the use of electronic systems in your place of work, including security, confidentiality and appropriate usage.
Records must be completed accurately and without any falsification and provide information about the care given as well as arrangements for future and ongoing care.
Jargon and speculation should be avoided.
When possible, the person in your care should be involved in the record keeping and should be able to understand what the records say.
Records should be readable when photocopied or scanned.
In the rare case of needing to alter a record, the original entry must remain visible (draw a single line through the record) and the new entry must be signed, timed and dated.
Records must be stored securely and should only be destroyed following your local policy.

Countersigning:

Nursing record keeping can be delegated to health care assistants (HCAs), assistant practitioners (APs) and nursing students so that they can document their care.
As with any delegated activity, the nurse needs to ensure that the HCA, AP or student is competent to undertake the activity and that it is in the patient’s best interests for record keeping to be delegated.
Nursing - Supervision and a countersignature are required until the HCA, AP or student is deemed competent at keeping records.
Registered nurses should only countersign if they have witnessed the activity or can validate that it took place
Always follow your local policy, further guidance can be found within the document “NMC Record keeping for Nurses and Midwives”.

The Data Protection Act 1998 deﬁnes a health record as “consisting of information about the physical or mental health or condition of an identiﬁable individual made by or on behalf of a health professional in connection with the care of that individual”.

The principles of good record keeping apply to all types of records, regardless of how they are held. These can include:

Handwritten clinical notes
Emails
Letters to and from other health professionals
Laboratory reports
X-rays
Printouts from monitoring equipment
Incident reports and statements
Photographs
Videos
Tape-recordings of telephone conversations
Text messages

Failure to maintain records could potentially cause considerable difficulties in respect of any legal proceedings, e.g. an allegation of negligence. Information is essential to the delivery of high quality evidence-based health care on a day-to-day basis. Records are a valuable resource because of the information they contain. This information can facilitate clinical decision making, improved patient care through clear communication of the treatment rationale and progress, and facilitate a consistent approach to team working. However, a record is only of use if it is correctly recorded in the first place, regularly up-dated, and easily accessible when it is needed. Everyone working in healthcare that records, handles, stores, or otherwise comes across information, has a personal common law duty of confidence to comply with this.

All patient attendance, non-attendance, and refusal of treatment and advice must be noted. It is advisable to note when telephone contacts are made. It is imperative that the agency worker dealing with a particular patient on a specific day can be identified; this means the patient’s attendance is dated and signed either in the agency workers records or on a register, or both. All patient records should be kept confidential in line with the Date Protection Act 1998.

Records Management

You must treat information about patients and clients as confidential and use it only for the purpose for which it was given. You must guard against breaches of confidentially by protecting information from improper disclosure at all times. Where there is an issue of child protection you must act at all times in accordance with national and local policies.

All records relating to the provision of our service are to kept for a period of eight years. Each client has an absolutes right to confidentiality and privacy regarding the services they are receiving in accordance with Data Protection Act 1998 and Human Rights Act 1999 and your agreement with the Company. Any concerns you may have regarding confidentiality can be discussed with our Recruitment Director or Nursing Manager.