A6.1 Your Role In Relatiom To Record Keeping An Audite

Question 1

What is a record?

Answer 1

Any information about an individual that is collected by being written down or recorded electronically

Question 2

What is our role in record keeping in healthcare?

Answer 2

• ensuring timely, accurate records for every interaction and how you have provided care for the individual
• ensure you are competent in using systems to record data where applicable
• ensure confidentiality/security is not compromised by using unprotected data or disclosing information in public places
• ensure the information recorded is factual and recorded in line with legislative requirements
• avoid abbreviations where possible

Question 3

What is an audit?

Answer 3

An audit is when a review or inspection is carried out to ensure compliance with regulations, policies and legislations

Question 4

What is our responsibility with record keeping?

Answer 4

• ensure information is legible where records have been recorded by hand
• all information must be legible
• ensure all records have a date, time and signature
• use a signature rather than initials
• ensure care is taken to enter record accurately if using electronic systems