Definition Flashcards
Why is essential to keep clear concise and accurate records (4)
To demonstrate accountability
To meet legislation
To protect practitioners
To prevent harm to patients and their significant others
What is a record
The Data Protection Act (1998) defines a health record as ‘‘Information about the physical or mental health condition of an identifiable individual made by or on behalf of a health professional in connection with the care of that individual
HCPC Standards of conduct performance and ethics says you must keep accurate records and must:
Keep records of everyone you treat
Complete all records promptly
Be clearly written and easy to read and you should write sign and date all entries
Update them including info re arrangements for continuity of care
Protect info in records from being lost, damaged, accessed by someone without appropriate authority
If you update a record you must not delete information that was previously there or make that information difficult to read
Only use accepted terminology
Handle records in accordance with applicable legislation, protocols and guidelines
Why keep records
Helps to improve accountability
Shows how decision related to patient care were made
Makes continuity of care easier
Provides documentary evidence of services delivered
Helps to address complaints
Helps to identify risks and enable early detection of complications
Promotes better communication and sharing of information between members of the multi-professional healthcare team.
