Clinical Record Keeping Standards

Target Audience

Who Should Read This Policy

All staff who contribute to service user’s records including     student nurses and bank staff

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Ref. Contents Page

1.0 Introduction 4 2.0 Purpose 4 3.0 Objectives 4 4.0 Process 4 5.0 Procedures connected to this Policy 14 6.0 Links to Relevant Legislation 14 6.1 Links to Relevant National Standards 16 6.2 Links to other Key Policies 17 6.3 References 18 7.0 Roles and Responsibilities for this Policy 19 8.0 Training 21 9.0 Equality Impact Assessment 21 10.0 Data Protection and Freedom of Information 21 11.0 Monitoring this Policy is Working in Practice 23

Appendices 1.0 Record Keeping Signature Sheet 25 2.0 List of Approved Abbreviations (Template) 26 3.0 Electronic Record Keeping Audit Tool 27 4.0 Record Keeping Audit Process Map 29 5.0 Mental Health Division Clinical Abbreviation List 30

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Explanation of terms used in this policy

Clinical Record - A collection of information about the care of a service user, provided by a range of healthcare professionals accountable to the Trust. If inpatients this must be made available at all times during the service users’ stay

Service User - Refers to patients including children

Medico-legal Record - Concerned with both medicine and law, as when doctors are approached to provide medical reports in connection with legal action and this can involve attending court to give evidence

Health Record - A single record with a unique identifier containing information relating to the physical and/or mental health and/or social care of a given service user who can be identified from that information and which has been recorded by or on behalf of, a health and/or social care professional in connection with the care of that service user. This may comprise of text, sound, image and/or paper and must contain sufficient information to support the diagnosis, justify the treatment and facilitate the ongoing care of the service user to whom it refers.

Therefore, it relates to a record being anything, which contains information (in any form or media) which has been created or received and maintained by the Trust as a result of any aspect of the work of their employees and/or contractors which is retained as evidence of that activity such as:  Service User related records (electronic or paper based)  Microfiche or electronically digitalised health and social care records  Audio and videotapes, cassettes, photographs

NHS Number - Introduced in 1996, the NHS number is the only national unique service user identifier in operation in the NHS at this time. A ten digit number assigned to every individual registered with the NHS in England and Wales

Clinical Information System - Electronic service user administration system which records the service user's demographics (e.g. name, home address, date of birth) and details all service user contact with the hospital, both outpatient and inpatient

Venous Thromboembolism (VTE) Risk Assessment - A risk assessment to determine the risk for venous thromboembolism (a disease that includes both deep vein thrombosis and pulmonary embolism) in a service user

Health of the Nation Outcomes Scales (HoNOS) - 12 simple scales on which service users with severe mental illness are rated by clinical staff. The idea is that these ratings are stored, and then repeated - for example after an intervention - and then compared. If the ratings show a difference, then that may indicate that the service user's health or social status has changed. They are therefore designed for repeated use, as clinical outcomes measures

Contemporaneous - A term used to state that records should be written at the time of, or as close to, the event described in the record

Audit - A method for systematically reflecting on and reviewing practice to ensure compliance with current standards

Caldicott Guardian - A senior person within the Trust responsible for protecting the confidentiality of service user information and enabling appropriate information-sharing

Better Records, Better Outcomes Leaflet – A leaflet given to all new starters summarising the health care record standards

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1.0 Introduction Clinical record keeping is an integral part of professional practice, designed to inform all aspects of the care process. Health care records enable health professionals to maintain a record of diagnoses made, treatment given and the service user’s progress. Aggregated, they form a permanent account of individual considerations and the reasons for decisions. The use of this information is a key element in supporting the everyday aspects of the delivery of high quality, evidence based health care. Good record keeping also improves accountability, can provide a medicolegal record of the care provided and is fundamental to good risk management practice. It is therefore essential that all records are correctly, accurately and legibly recorded, up to date and easily accessible to those who need to use them.

Record keeping standards are the minimal requirements for all staff to adhere to in the achievement of effective safe record keeping and documentation of clinical care. The standards set out in this policy do not replace standards set by professional organisations but are complementary to them.

The benefits of good record keeping include:  Promoting high standards of clinical care by acting as a tool for assessment, treatment and care delivery  Providing a means of enhancing patient safety, minimising the likelihood of delays or inappropriate care  Providing an accurate account of treatment and care planning  Promoting effective communication that delivers continuity of care between members of the multidisciplinary health care team  Demonstrating that care follows evidence-based guidance or evidences variances including decisions not to treat  Acting as a record of any problems that have arisen such as changes in the service user’s condition and actions taken as a result

2.0 Purpose The aim of this policy is to provide direction and guidance to staff on how to meet the standards required for the recording of information within health care records.

3.0 Objectives  Comply with best practice and current legislation  Set out the Trust’s clinical record keeping responsibilities  Identify the standards of record keeping to ensure that all clinical records are complete and accurate with regards to the information they contain  Improve awareness and understanding of maintaining adequate records to account fully for all care given to individual service users and to provide a clear and chronological record of that care

4.0 Process

4.1 Record Keeping – Principles The principles of good record keeping apply to all types of records, regardless of how they are held. These include:  Handwritten clinical notes  Electronic health records (including scanned records)

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 Mental Health records  Emails  Letters to and from health professionals  Laboratory reports  X-rays  Printouts from monitoring equipment  Incident reports and statements  Photographs  Text messages  Letters/ reports to external agencies

The basic principles of good record keeping are:  Be factual, consistent and accurate  Be written in black ink  Be written as soon as possible after an event has occurred and/or discovered, providing current information on the care and condition of the service user. This should be by the end of the shift for inpatient areas and within 24 hours for community staff  Be written clearly, legibly and in such a manner they cannot be erased. In the event of an error being made, entries must be corrected by striking the error through with one line, writing ‘error’ and continuing with the correct word. The author must apply their initial by the correction. The original entry should still be read clearly. Errors must not be amended using white correction fluid, scribbling out or writing over the original  Be accurately dated, timed, signed, the name should also be printed and designation and qualification included. Stamped format is acceptable  Keep abbreviations to a minimum and used from an approved abbreviations list (abbreviations should be approved by relevant Group Quality and Safety Group)  Every entry in the medical record should identify the most senior Health Care Professional present who is responsible for decision making at the time the entry is made  Be easily identifiable - NHS number, electronic system number  Be written, wherever possible, with the involvement of the service user or carer and in terms that the service user or carer will be able to understand  Be consecutive  Be bound and stored so that loss of documentation is minimised and confidentially maintained  Be readable and remain readable even when reproduced, e.g. photocopy/ fax  Be in English (if service user requires a copy in their own language, this has to be facilitated and copied for their records - attaching it to the English version)  Be relevant and useful: - Identifying problems that have arisen and the action taken to rectify them - Providing evidence of the care planned the decisions made and reviewed, the care delivered and the information shared - Providing evidence of actions agreed with the service user (including consent to treatment and/ or consent to share) - Including clinical observations: examinations, tests, diagnoses, prognoses, prescriptions, other treatments - Including relevant disclosures by the service user – pertinent to understanding cause or effecting cure/ treatment - Including facts presented to the service user

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- Including correspondence from the service user or other parties - Identifying clear escalations of concerns when service user’s needs are not being met – i.e. safeguarding - Providing evidence of multi professional working - Details of all professional, voluntary, independent and others involved in service user’s care

Service user records should not include:  Unauthorised abbreviations, jargon, meaningless phrases, irrelevant speculation and offensive subject statements  Personal opinions regarding the service user (restrict to professional judgements on clinical matters)  The name(s) of third parties involved in a serious incident. The name should be included on the separate incident form for cross referencing  Correspondence generated from legal papers and complaints

4.2 Record Keeping Standards The standards below are the minimum requirements expected by the Trust of those involved in the delivery of care to service users. These standards do not replace those produced by professional regulatory bodies but are intended to compliment them.

4.2.1 Records must be complete The health care record is the complete care record.

Subsidiary records e.g. number of contacts; out-patient appointments; personal details; care programme approach; safety warnings etc. are recorded and maintained on the appropriate clinical information system.

Once a referral has been accepted and a decision made to provide care, the following, as a minimum, must be completed if appropriate for service/ client:  A search made for any separate health care records in relation to the service user  A search of any other agencies involved in the service user’s care  Service user demographics e.g. name, address, date of birth, NHS number, ethnicity (this can be in the form of a printed sticker) on every page  Physical examination (for all inpatients) to include VTE risk assessment (In CYP - holistic initial assessment to be completed)  Comprehensive assessment including capacity/ competence and legal status where appropriate  Completed risk assessment tool, e.g. Sainsbury's risk assessment tool,  Any alert information – following alert protocol and including, risk to self, to others, allergies and any other medical issues. This should be easily identifiable at the front of the file  Health of the Nation Outcomes Scales (HoNOS) where relevant (or other outcome measurement tool)  Valid consent documentation  Advanced decisions to refuse treatment consent and cardiopulmonary resuscitation decisions must be clearly recorded in the medical record and in circumstances where that person is not the decision maker that person should be identified  Care plan – comprehensive plan of care formulated from assessment and incorporating a risk/ crisis plan

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 Care plan reviews  Intervention plans  Carer’s information  Provide patients' rights information – especially in relation to detainment under the Mental Health Act 1983  Provide Service/ unit information so service users are clear about the nature of service, expectations and how to raise concerns  Complete Physical Health and Well Being Booklet where relevant  Regular, timely consecutive progress notes including summaries of assessments, results of bloods/ tests and resulting actions, care decisions, treatments and interventions etc.  Discharge record summary should be commenced at the time a patient is admitted to hospital

4.2.2 All handwritten clinical entries must be dated, timed and signed, the name should also be printed and designation and qualification included of the person making the entry at the time of documentation  The recording of primary clinical information must always be in the health care record  Where clinicians choose to maintain their process notes as an electronic record they should be mindful of their responsibility and accountability in ensuring that the entry made on the appropriate clinical information system is a reflection of the relevant information upon which actions may be taken  Signature sheets must be signed and dated for all first entries (see Appendix 1)

4.2.3 Staff must be made aware of, and understand, the business continuity arrangements for records  Every clinical service must have a business continuity plan as part of their change management processes. Managers must ensure their staff are aware of these plans which will describe how care will continue to be provided in the event that the health care record cannot be accessed or vital information held on electronic records cannot be accessed  Further guidance on issues to be considered can be obtained from the Records Service Manager

4.2.4 Clinicians must always make their own entries in the clinical records  If extenuating circumstances mean that a clinician cannot make a timely entry, they must contact an appropriate clinical colleague to record an entry on their behalf. The entry will need to be made as a third party entry, stated as such in writing and signed  It is recognised that, very occasionally, medical colleagues may have occasion to request their medical secretary to make a 'third party entry' on their behalf which will then need to be countersigned (any entries provided by a non-registered professional staff member must be countersigned by a registered professional). It is important to note that the consultant still remains accountable for the entry as soon as it is made

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4.2.5 Records must be kept in a secure place and be easily accessible (i.e. they can be found and retrieved when needed) The security of records is necessary to safeguard them from breaches of confidentiality. Health care records, when not in use, should be secured in a designated area, where possible they should be locked in a cupboard, filing cabinet or lockable trolley and then locked away in a secure office. Where possible the filing cabinet in which the records are locked should be fire proof.

When you are using the clinical information system adhere to these security rules:  Lock your monitor screen when it is not in use  Position your monitor away from public areas  Do not share your clinical information system password  Do not write down your clinical information system password

4.2.6 All demographic information must be completed Health care records are used to record demographic data, but such information must be inputted into the appropriate clinical information system. The data held in clinical information system must reflect the health care record and vice versa.

4.2.7 Demographic information must be checked for accuracy on a regular basis To help ensure compliance with the Data Protection Act 1998, the following demographic information must be checked with service users at least once a year:  Address  Contact phone number  Marital status and any subsequent name changes  GP registration  Other name changes

4.2.8 Every service user will be identified by their NHS number  The NHS number is central to the vision of seamless service user care and the life-long health care record  The NHS number must appear on every side of every page of all correspondence related to the service user e.g. When sending blood samples to an acute trust laboratory for analysis you must state the client’s NHS number on the sample identification label or when sending a letter to the service user, you must state the NHS number on the letter  NHS numbers can be found and verified on the NHS Spinal Record  Access to this system requires a smart card and pin number which some administrative staff in clinical areas have access to  Where there is no access to a smart card or pin number then contact should be made via the Information Services Helpdesk

4.2.9 The information in the health care record must be arranged in chronological order according to filing instructions on section dividers  Handwritten notes must be filed with the past history at the front of the section and the most recent history at the back  Correspondence/ letters to be filed in date order with the most recent documentation at the back of the section

NB: clinical entries entered into the clinical information system do not need to be printed out unless your service business continuity plan indicates otherwise.

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4.2.10 All paper based documents relating to the service user must be filed in the appropriate sections of the case note folder according to filing instructions  File papers and documents behind the section dividers; not on top of them  Each section divider has printed filing instructions  Where emails are used they should be printed and filed with correspondence section

4.2.11 Entries into the record should be contemporaneous Information recorded about the service user should be written at the time of the event or as soon afterwards that is possible to provide a chronological and accurate record of events. This is vitally important as it captures the reality of the events within which the service user care was delivered and can be used in evidence in any legal proceedings.

If contemporaneous notes cannot be made then entries should be made as soon as possible after the event and completed within 24 hours of the event. This will ensure records are always up-to-date.

 Entries must have a date and time of appointment or intervention and when records were complete next to them  Time must be recorded in 24 hour clock

The Trust acknowledges there are occasions where 24 hour entries are not applicable e.g. where a home visit is made Friday late afternoon it may not be possible to meet the 24 hour completion dates. If this is the case, significant information especially that associated with risk must be conveyed via a third party entry by a clinical colleague (see 4.2.4).

4.2.12 If a significant time has elapsed between entries there must be an explanation The frequency of entries will be determined by the registrant’s professional judgement and local standards and agreements. However good practice standards are:  An entry should be made in the medical record whenever a patient is seen by a doctor. Within Inpatients, if there is no entry for more than 4 days for Acute services and 7 days for other services, the next entry should explain why  Inpatient notes - usually one entry per shift in accordance with clinical presentation. Community notes - one entry per contact

Registrants may be required to make more frequent entries for service users who:  Present with complex problems  Show deviation from the norm  Are vulnerable or at risk of harm or abuse  Require more intensive care than usual  Are confused and disoriented or generally give cause for concern

Clinical staff must use their professional judgement and, if necessary, in discussion with other members of the health care team, to determine whether these circumstances exist. Such scenarios may be more applicable to an inpatient setting. For example an entry into a client’s notes has been omitted during the afternoon shift. It is the responsibility of the next staff member (from the night shift) to write into the notes, to raise this at handover time to staff on the morning shift and then for

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4.2.13 Entries into the record must be legible  Handwritten entries are for others to read, not your own personal use; staff must make real efforts to write in a clear handwriting style, with good grammar and correct spelling. Discuss any handwriting/ spelling issues with your manager, in supervision  Keep entries factual, accurate and non-judgemental  It is acceptable to record professional opinion and interpretation of data but it must be noted as such. Bear in mind that family members may access records so tact may be required when recording information  Service users may access their records so record information in terms that the service user can understand. All information recorded about a service user is potentially disclosable under the Data Protection Act 1998

4.2.14 Entries must be written in indelible, photocopiable, black ink  With the exception of Pharmacists who may need to use coloured ink  Do not use highlighter pens in the clinical records

4.2.15 All documents relating to the service user must be bound directly into the file; there should be no loose pages, plastic wallets, post-its, staples, highlighter pens Paper ‘Storage’ envelopes may be used for keeping items unspoiled and secure, for example:  Children’s artwork  Paper traces from machine recordings e.g. EEG and ECG traces  Handwritten notes written by service users

There is space provided on the front of the envelope to catalogue its contents; please ensure you use this where needed.

4.2.16 No pencil erasers or correction fluids are allowed in the records If a correction, alteration or addition is necessary you must cross through the error with a single line, initial, write ‘error’ and continue with the correct word. If an entry is in the wrong notes, cross through the note, write ‘error’, initial and then, in the next available space , write’ disregard entry of (date and time) as written in incorrect record’: sign and date as with any note. Transparency relies on the old entry remaining readable.

Do not erase, obscure or scribble out errors – let them remain readable.

If an entry that was made several days ago is found to be incorrect, write an entry: Entry made on (date) and (time) is inaccurate – it says (this) but should say (this)’, sign and date as usual. Do not write on/ in the correct note.

If the correction was due to an obvious spelling or grammar mistake you do not have to justify the reason for alteration

4.2.17 There must be no gaps  There must be no gaps between entries, no “ditto” lines and no blank pages  If an entry has finished part way along a line the remaining blank part of the line must be crossed through to clearly mark the end of the entry Version 2.1 April 2017 10

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4.2.18 Keep abbreviations to a minimum  Abbreviations should be kept to a minimum, and only to be used within the record where they are written out in full at first use on each page  It has been agreed that clinicians may use abbreviations as listed in the back of the British National Formulary  Abbreviations lists are reviewed and managed within Service areas and approved by Group Quality and Safety Steering Groups (see Appendix 2)

4.2.19 Information on allergies and major medical problems must be recorded on the medical alerts at the front of the health care record  The medical alerts panel is located on the front inside cover of the health care record. Do not cover this panel with other documentation  The panel must be left clear so it is the first thing visible when the file is opened. Record the source of information, e.g. GP letter states no known allergies or client states no known allergies  Also record the date the allergy/ medical problem was recorded onto this sheet or the date the service user was asked about allergies/ medical problem

4.2.20 Significant risks must be recorded There is a section in the health care record for filing risk assessments and risk management plans.

4.2.21 Ensure blood and other investigation and laboratory results have been signed for and filed in the appropriate section within the record  The responsible medical officer should sign test results to signify they have looked at and understood the results  The person who signs must take appropriate action in the event of an abnormal result, e.g. ‘RED’ Clozapine or toxic lithium result  Remember to record client’s NHS number on blood samples and other investigations  File test results on the appropriate mount sheet according to the investigation carried out  Investigation and laboratory results received over the phone or web must be recorded within the clinical record with a stated interpretation/ analysis/ comparative analysis, where relevant, with previous/ past results and any actions to be taken  Just listing the results in the records is not acceptable

4.2.22 Records must document other professionals’ involvement in the care of the service user  The full name (first and last name), position and profession of any other health care worker involved in the care must be clearly recorded (never record first names only)  All non-registered clinical staff making independent clinical entries in electronic case notes or paper clinical records must be competent to do so  Only staff who are competent in clinical record keeping may make entries in the clinical record; thus removing the need for countersignature. However countersignatures in paper records and verification of entries in electronic records are required in certain situations  If student nurses, student allied health professionals and medical students have been trained to appropriate standards, are competent to produce records as part

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of the overall provision of care and it is in the service user’s best interests for recording of care (as well as care provision) to be delegated there will be no requirement for the registered nurse to countersign the notes. Until they are deemed wholly competent, countersigning should be performed. If registered nurses are required to countersign they should only do this if they have witnessed the activity or can validate that it took place. Students must ensure that the records are countersigned before they leave the shift. The registered nurse retains professional accountability for the appropriateness of the delegation of the task, but the student takes on personal accountability for the content and quality of the records

4.2.23 Records must document the involvement of other external agencies as part of collaboration with or partnership working in the care of the service user  Staff must ensure they document the details and involvement of any other external agencies involved in the care of the service user  This may be as a result of collaboration or partnership working to improve outcomes for service users, or to evidence where people with complex needs require and receive support from multiple agencies  The name of each agency (avoid abbreviations) and the contact details of each agency involved in the care of the service user must be clearly recorded.  Followed by a summary of the involvement the service has had with each external agency in the care of the service user. Documenting the name and position of the person from an external agency involved in the care of the service user is helpful while recognising that this is likely to change over a period of time.

4.2.24 Make entries for all appointments, even those cancelled or not attended  You must always record the reasons given for any cancellations or non- attendance and an indication about future appointments  There are two types of cancellation: Trust cancellation and service user cancellation. The reasons for both types of cancellation must be recorded in the notes. This information is a clinical entry and as such should be made by the clinician

4.2.25 Ensure that you always use Trust approved documentation for the purpose of record keeping  The Trust has a document library that holds all Trust approved record proformas, assessments and clinical record sheets. Original documentation must be used each time a record is created  Photocopies of forms and clinical record sheets are not acceptable  Photocopied text deteriorates in quality when it is copied over and over  Clinical record sheet paper is thicker than standard photocopy paper and is less likely to tear and become detached from the record  It is the responsibility of healthcare professionals and administrative staff to work together to ensure that sufficient supplies are maintained at all times  There should be no current documentation bearing the names of any former Trusts that may have merged with the Trust  Approved documentation should bear the Trust's name only

4.2.26 Individual clinical records must be created after the multi-disciplinary team (MDT) has made the decision to accept the client into the care of the trust or when birth notification is received in CYPF

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 All discussions, decisions and subsequent actions by the MDT prior to accepting or declining a service user should be recorded and documented  All discussions, decisions and subsequent actions by the MDT, care delivered and the information shared must be clearly recorded and documented

4.2.27 Records should be written with the involvement of the service user wherever possible  Where appropriate, notes can be written using the service user's own words  Service users should always be involved with the formulation of their care plans, assessments and care decisions  Always try to secure the signature of service users on care plans and other appropriate documentation. State the reason given for any unsigned documentation where the service user's signature is required e.g. lacking capacity

4.2.28 Disclosures of a child protection/ child welfare and adult at risk nature  Record, word for word, any disclosures made relating to abuse and welfare issues. However, any subsequent investigations or reports must be filed in the third party section of the care records  Any risk issues must be recorded on the appropriate clinical information system via the Safeguarding electronic marking procedures  Please refer to the Trust's child protection policy, Safeguarding Adults at Risk Policy or contact the named nurse for safeguarding for advice on any safeguarding issues

4.2.29 Ensure that reported information is acknowledged and clearly marked ‘third party’ to prevent disclosure without appropriate consent Healthcare professionals who have compiled or contributed to the health care records or who have been involved with the care of the service user are generally not considered to be third parties.

However, any other pieces of information received from others will require the author's permission before disclosing to the service user or other parties. Examples of third party information:  Multi-Agency Public Protection Arrangements (MAPPA) - MAPPA documentation should always be stored in the third party section as clients should never be allowed to see this  School reports  Housing authority reports  Anti-Social Behaviour Order reports from the police  Reports from external sources  Electronic marker notification forms  Legal documentation/ correspondence  Family statements, reports  Vulnerable Adult Protection (VAP) forms/ investigations

4.2.30 Ensure you explain to service users why we ask them for personal information and how that information will be used ‘Your health care record, Information for the public’ leaflet should be given to service users at the beginning of an episode of care.

 By law, everyone working for or on behalf of the NHS must respect confidentiality and keep all service user information secure. All health care records are private

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and personal so it is the top priority of the NHS to make the process of accessing information (paper and electronic) secure  All staff must ensure they comply with the NHS and trust confidentiality codes of practice and professional codes of conduct  The Trust will take action when someone deliberately looks at records about a service user without permission or good reason or shares those records/ that information with others without good reason or permission to do so

4.2.31 Management of Diaries Diaries are also part of the clinical record; staff should be aware of their responsibilities in maintaining their diary.

 Entries must be work related. Personal information that staff don’t want shared should not be written in the diary  Entries should be legible and in black ink. Tippex should not be used, errors or changes should be scored through with a single line  Diaries can be used to record, appointments, visits, mileage (optional), relevant occurrences and contacts  Entries related to a specific service user should be transferred to the service user clinical record as soon as is practicable and within the standards defined in this policy  Diary entries can relate to telephone and face to face contact  Service users identifier to be used to ensure non-identifiable data in the event of loss  Care of the diary is important, e.g. general appearance, keep binding intact, kept in confidential place  Diaries to be made available for checking (e.g. by line manager or for audit purposes)  Diaries to be kept at the end of the year; diaries should be archived and retained for a minimum of 2 years (after the last date in the diary). They can then be disposed of as confidential waste  Lost diaries should be reported on an incident form

5.0 Procedures connected to this Policy Standard Operating Procedure 1 (SOP 1) Patient Identification

6.0 Links to Relevant Legislation

Care Act 2014 Care Act 2014 highlights that good record keeping is a vital component of professional practice and staff should be given clear direction as to what information should be recorded and in what format. The act also states that records should be kept in such a way that the information can easily be collated for local use and national data collections.

Whenever a complaint or allegation of abuse is made, all agencies should keep clear and accurate records and each agency should identify procedures for incorporating, on receipt of a complaint or allegation, all relevant records into a file to record all action taken. When abuse or neglect is raised managers need to look for past incidents, concerns, risks and patterns. In the case of providers registered with CQC, records of these should be available to service commissioners and the CQC so they can take the necessary action.

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All agencies should identify arrangements, consistent with principles and rules of fairness, confidentiality and data protection for making records available to those adults affected by, and subject to, an enquiry.

Agencies should draw up a common agreement relating to confidentiality and setting out the principles governing the sharing of information, based on the welfare of the adult or of other potentially affected adults. Any agreement should be consistent with the principles set out in the Caldicott Review.

Public Records Act 1958 The Act sets out broad responsibilities for everyone who works with NHS records, defined as public records under the Act.

Data Protection Act 1998 The Data Protection Act 1998 became law in March 2000. It sets standards that must be satisfied when obtaining, recording, holding, using or disposing of personal data. The law applies to data held on computers or any sort of storage system, including paper records.

There are 8 enforceable principles of good practice. Data should be:  Fairly and lawfully processed  Processed for limited purposes  Adequate, relevant and not excessive  Accurate  Not kept longer than necessary  Processed in accordance with the data subject's rights  Secure  Not transferred to countries outside the European Economic Area (EEA), without adequate protection

Freedom of Information Act 2000 The Freedom of Information (FOI) Act gives a general right of access to all types of recorded information held by public authorities, including NHS Trusts. The Act also sets out exemptions to that right and places certain obligations on public authorities.

In addition to providing information when asked to do so, FOI also requires public authorities to be proactive in the release of information.

Every public authority is required to adopt and maintain a publication scheme setting out how it intends to publish the different classes of information it holds, and whether there is to be a charge for the information disclosed. The Trust’s FOI publication scheme is regularly updated and has been approved by the Information Commissioner.

Access to Health Records Act 1990 Access to Health Records Act 1990 (AHRA) provides certain individuals with a right of access to the health records of a deceased individual. These individuals are defined under Section 3(1) (f) of that Act as, ‘the patient’s personal representative and any person who may have a claim arising out of the patient’s death’. A personal representative is the executor or administrator of the deceased person’s estate.

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There are also a range of public bodies that have lawful authority to require the disclosure of health information. These include the Courts, legally constituted Public Inquiries and various Regulators and Commissions e.g. the Audit Commission and the Care Quality Commission. In these cases the common law obligation to confidentiality is overridden.

Mental Capacity Act 2005 The Act is designed to provide a legal framework for acting and making decisions on behalf of adults who lack the capacity to make particular decisions for themselves.

The Act outlines 5 statutory principles. These are designed to protect people who lack capacity to make particular decisions, but also to maximise their ability to make decisions, or to participate in decision-making, as far as they are able to do so.

1. A person must be assumed to have capacity unless it is established that he/she lacks capacity 2. A person is not to be treated as unable to make a decision unless all practicable steps to help him/her to do so have been taken without success 3. A person is not to be treated as unable to make a decision merely because he/she makes an unwise decision 4. An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his/ her best interests 5. Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action

Equality Act 2010 Equality Act came into force on 1 October 2010 and brought together over 116 separate pieces of legislation into one single Act to provide a legal framework to protect the rights of individuals and advance equality of opportunity for all. The Act simplifies, strengthens and harmonizes the current legislation to provide a new discrimination law which protects individuals from unfair treatment and promotes a fair and more equal society.

6.1 Links to Relevant National Standards

CQC Regulation 17: Good Governance The intention of this regulation is to make sure that providers have systems and processes that ensure that they are able to meet other requirements in this part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulations 4 to 20A). To meet this regulation; providers must have effective governance, including assurance and auditing systems or processes. These must assess, monitor and drive improvement in the quality and safety of the services provided, including the quality of the experience for people using the service. The systems and processes must also assess, monitor and mitigate any risks relating the health, safety and welfare of people using services and others. Providers must continually evaluate and seek to improve their governance and auditing practice.

In addition, providers must securely maintain accurate, complete and detailed records in respect of each person using the service and records relating the employment of staff and the overall management of the regulated activity. Version 2.1 April 2017 16

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As part of their governance, providers must seek and act on feedback from people using the service, those acting on their behalf, staff and other stakeholders, so that they can continually evaluate the service and drive improvement.

When requested, providers must provide a written report to CQC setting out how they assess, monitor, and where required, improve the quality and safety of their services.

Information Governance Toolkit The Information Governance Toolkit is a Department of Health (DH) Policy delivery vehicle that the Health and Social Care Information Centre (HSCIC) is commissioned to develop and maintain. It draws together the legal rules and central guidance set out by DH policy and presents them in in a single standard as a set of information governance requirements. The organisations in scope of this are required to carry out self-assessments of their compliance against the IG requirements.

Records Management Code of Practice for Health and Social Care 2016 The Records Management Code of Practice for Health and Social Care 2016 has been published by the Information Governance Alliance (IGA) for the Department of Health (DH).

The Code is a guide to be used in relation to the practice of managing records. This Code is relevant to organisations who work within, or under contract to NHS organisations in England. This also includes public health functions in Local Authorities and Adult Social Care where there is joint care provided within the NHS.

The Code is based on current legal requirements and professional best practice. It will help organisations to implement the recommendations of the Mid Staffordshire NHS Foundation Trust Public Inquiry relating to records management and transparency.

6.2 Links to other Key Policies

Risk Management Policy The purpose of the Risk Management Policy is to provide an effective framework through which the Trust can safely and effectively manage risks.

Being Open and Duty of Candour Policy The purpose of this policy is to explain the meaning of Being Open and Duty of Candour in practice by providing clear information to staff to enable them to have the confidence to communicate and act appropriately with patients, their families and carers when things go wrong.

Incident Reporting Policy The purpose of this policy is to make clear the system used for reporting incidents involving patients, staff and others undertaking activities on behalf of the Trust.

Health Records Policy This policy is intended to be a comprehensive guide to all staff involved in the handling of health records and the associated documentation providing a framework

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This policy defines the structure to ensure complete and accurate records are maintained and they are managed and controlled effectively and comply with our legal, operational and information needs. It will also set down the standards required of staff when dealing with health records and the associated documentation.

Discharge and Transfer of Care Policy The purpose of this policy is to ensure that discharge or transfer from services managed by the Black Country Partnership NHS Foundation Trust is effective, consistent and organised around the needs of individual service users and carers.

6.3 References  Nursing and Midwifery Council (2009) Record Keeping: Guidance for Nurses and Midwives  Royal College of Nursing (2014) Delegating Record Keeping and Countersigning Records: Guidance for Nursing Staff  NHS Professionals (2010) CG2 – Record Keeping Guidelines  Nursing and Midwifery Council (2015) The Code: Record Keeping Guidance  British Medical Association (2014) Access to Health Records: Guidance for Health Professionals in the United Kingdom  Good Medical Practice, General Medical Council (2013)  Good Psychiatric Practice, Royal College of Psychiatrists, 2009  The British Psychological Society (2002) Guidelines on Confidentiality and Record Keeping: Division of Counselling Psychology  College of Occupational Therapists (2011) Professional Standards for Occupational Therapy Practice: Record Keeping  Core Standards of Physiotherapy Practice, Chartered Society of Physiotherapy, 2005  Royal College of Speech and Language Therapists (2011) Guidance on Quality Standards for Local Authorities and Schools as Commissioners of Speech and Language Therapy Services in the UK  Health and Care Professions Council (2013) Standards of Proficiency: Occupational Therapists  Legal aspects of documentation. Exploring common deficiencies that occur in record keeping. British Journal of Nursing, Vol.14, Issue 10, p.568-571 2005  Health Professionals Council (2008) Standards of conduct, performance and ethics. London  Information Governance Alliance (2016) Records Management Code of Practice for Health and Social Care

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7.0 Roles and Responsibilities for this Policy

Title Role Key Responsibilities Students/ Bank Staff/ Adherence - Familiarise themselves with this policy Temporary Staff - Ensure that they familiarise themselves with the clinical records when on shift - Work within their area responsibility and competence All Trust Staff Adherence - Ensure that they keep appropriate records of their work in the Trust - Manage those records in keeping with this policy and with any other associated procedures/guidance approved by the Trust - Keep up to date with relevant training, best practice guidelines, policies, procedures and codes of practice Clinical Staff Adherence - Responsible for any records that they create, receive or use in the performance of their duties - Keep up to date with relevant training, best practice guidelines, policies, procedures and codes of practice - Staff who are professionally regulated also have the following duties: • Keep up to date with and adhere to relevant legislation, case law and national policy relating to information and record keeping • Keep up to date about best practice and record keeping standards • Maintain proficiency in the Trust’s systems and associated procedures to record information Corporate Governance Governance - Monitor all incidents reported via DATIX Trust’s electronic reporting system Assurance Unit - Initiate reports that are discussed at the Senior Managers/ Clinicians Weekly Conference Call and monthly meetings of Group Quality and Safety Groups and the Trust’s Quality and Safety Steering Group. These reports are then discussed at monthly Clinical Quality Review Meetings with Commissioners - Ensure all serious incidents are reported to commissioners and NHS England via the Strategic Executive Information System (StEIS) within two working days Caldicott Guardian - Reflect service users’ interests regarding the use of patient identifiable information - Protect the confidentiality of service user information - Enable appropriate information-sharing - Ensure that the Trust satisfies the highest practicable standards for handling patient identifiable information - Ensure patient identifiable information is shared in an appropriate and secure manner Ward Managers/ Team Operational - Ensure that the clinical record keeping process within their area of responsibility adheres to this policy Leaders/ Matrons - Ensure that staff attend training applicable to their role - Report concerns to their service manager - Ensure quarterly electronic audits are completed and action plans developed Records services Operational Lead - Ensure that the records management systems and processes are developed, co-ordinated and monitored across the Trust Manager - Assist groups and services to achieve good record keeping and compliance with the relevant standards, legislation, policies and procedures relating to the management of records

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Title Role Key Responsibilities Service Managers Implementation - Ensure systems are in place to enable this policy to be implemented within their service area and that they are familiar with the policy - Support their teams in ensuring effective clinical record keeping and supporting any challenges with the process that may arise - Ensure consideration is always given to clinical record keeping standards when undertaking managerial activities such as supervision, service objectives, improvements or developments - Ensure they report any concerns to the Group manager Group Directors and Leads - Ensure all managers are aware of the policy and promote good practice Group Managers - Provide support and guidance regarding resources to enable this policy to be implemented - Ensure clinical staff implement safe systems of work in accordance with the procedures referred to in the policy Information Responsible - Monitor clinical record keeping standards across the organisation as part of the work they undertake in respect of the Governance Steering information governance toolkit Group - Discuss the results of paper and electronic clinical record keeping audits Group Quality and Monitor - Monitor clinical record keeping standards within their group (Membership is representative of the division as a whole multi- Safety Groups disciplinary in nature, with a mix of representatives from each of the service areas, professional leads, practice development professionals and representatives from clinical sub-groups) - Receive the results and recommendations of all completed clinical audits - Monitor any subsequent actions plans to completion - Authorise documentation to be used within the group Quality and Safety Scrutiny and - Oversee the implementation of a systematic and consistent approach to the clinical record keeping process Steering Group Performance - Provide exception and progress reports to the Quality and Safety Committee

Quality and Safety Scrutiny and - Ensure that this policy is managed efficiently and effectively in accordance with the Board’s Assurance Framework and Committee Performance strategic priorities

Clinical Directors Leadership - Ensure clinical record keeping standards are maintained within their group - Lead discussions around clinical record keeping at Group Quality and Safety Steering Groups - Oversee the completion of audits in respect of clinical record keeping - Provide updates around clinical record keeping within their group to the Quality and Safety Steering Group Trust Board Strategic - Have a strategic overview and final responsibility for overseeing this policy in the Trust - Ensure legal responsibilities are met - Ensure internal and external governance requirements are adopted Executive Director of Executive Lead - Ensure that clinical record keeping standards are maintained Nursing, AHPs and - Ensure this policy is implemented Governance - Ensure a systematic and consistent approach to clinical record keeping standards across the Trust - Ensure Information Governance is applied throughout the Trust Chief Executive Accountable - Ensure that this policy is implemented within the Trust (operational responsibility has been delegated to Executive Director of Nursing, AHPs and Governance)

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8.0 Training

What aspect(s) of Is this training covered in the Which staff How often will Who will ensure and this policy will Trust’s Mandatory and Risk If no, how will the Who will deliver the groups require staff require monitor that staff have require staff Management Training Needs training be delivered? training? this training? training this training? training? Analysis document? The creation of a All staff involved No, staff will receive specific Training will be delivered Line Managers This will be Information Governance health record on in the creation of training in relation to this policy internally by relevant line determined on Steering Group the following: health records where it is identified in their managers an individual - Patient individual training needs analysis basis as part of their development for Administration their particular role and System responsibilities - Use of the Patient Master Index (PMI), - Use of National Spine and - Patient Document Tracking - Electronic Health Record System Training on how to create and use a paper based record and system

9.0 Equality Impact Assessment Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext. 8067 or email [email protected]

10.0 Data Protection and Freedom of Information Data Protection Act provides controls for the way information is handled and to gives legal rights to individuals in relation to the use of their data. It sets out strict rules for people who use or store data about individuals and gives rights to those people whose data has been collected. The law applies to all personal data held including electronic and manual records. The Information Commissioner’s Office has powers to enforce the Data Protection Act and can do this through the use of compulsory audits, warrants, notices and monetary penalties which can be up to €20million or 4% of the Trusts annual turnover for serious breaches of the Data Protection Act. In addition to this the Information Commissioner can limit or stop data processing activities where there has been a serious breach of the Act and there remains a risk to the data. Version 2.1 April 2017 21

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The Freedom of Information Act provides public access to information held by public authorities. The main principle behind freedom of information legislation is that people have a right to know about the activities of public authorities, unless there is a good reason for them not to. The Freedom of Information Act applies to corporate data and personal data generally cannot be released under this Act.

All staffs have a responsibility to ensure that they do not disclose information about the Trust’s activities; this includes information about service users in its care, staff members and corporate documentation to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies. The Information Governance Team provides a central point for release of information under Data Protection and Freedom of Information following formal requests for information; any queries about the disclosure of information can be forwarded to the Information Governance Team.

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11.0 Monitoring this Policy is Working in Practice

What key elements will be Where How will they be Who will Group/Committee Group/Committee Evidence How monitored? described in monitored? undertake this that will receive and to ensure actions this has Frequently? (measurable policy objectives) policy? (method + sample size) monitoring? review results are completed happened Clinical Directors, 7.0 Roles and All Incidents reported Governance Monthly Group Quality and Quality and Safety Minutes of Professional Leads and Responsibilities in groups in respect of Assurance Unit Safety Groups Steering Group meeting/ Group Quality and Safety for this Policy clinical record keeping action plans Groups are discharging their standards signed off responsibilities in respect of this policy Information received Governance Monthly Group Quality and Quality and Safety Minutes of in respect of concerns, Assurance Unit Safety Groups Steering Group meeting/ compliments, action plans complaints and claims signed off where clinical record keeping standards was a pertinent factor Group electronic audit Ward Managers/ Quarterly Information Group Quality and Minutes of and implementation of Team Leaders/ Governance Steering Safety Group meeting/ action plans Matrons Group action plans signed off Basic record keeping 4.2 Record All Incidents reported Governance Monthly Group Quality and Quality and Safety Minutes of standards, which must be Keeping in groups in respect of Assurance Unit Safety Groups Steering Group meeting/ used by all staff Standards clinical record keeping action plans standards signed off

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4.2 Record Information received Governance Monthly Group Quality and Quality and Safety Minutes of Keeping in respect of concerns, Assurance Unit Safety Groups Steering Group meeting/ Standards compliments, action plans complaints and claims signed off where clinical record keeping standards was a pertinent factor Appendix 3 Electronic audit - Ward Managers/ Quarterly Information Group Quality and Minutes of detailed review of Team Leaders/ Governance Steering Safety Group meeting/ practice taking account Matrons Group action plans of basic record signed off keeping standards and other key elements of policy Better Records, Better Induction checklist - Ward Managers/ Annually Information Group Quality and Minutes of Outcomes leaflet given to all leaflet to be given out Team Leaders/ Governance Steering Safety Group meeting/ new starters as part of induction Matrons Group action plans signed off

Please note individual areas will be responsible for devising service specific audits

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Appendix 1

Record Keeping Signature Sheet

Instructions: In accordance with the Trust's Clinical Record Keeping Standards Policy you must complete this sheet when making first entry in this record.

Date of Signature Name (In block Designation (in Verification name and First Entry capitals) block capitals) signature

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Appendix 2

List of Approved Abbreviations (Template)

Group: ______

 In accordance with the Trust's Record Keeping Policy, this list details those abbreviations that have been approved for use within the clinical record. No other abbreviations should be used  Only the Group Quality and Safety Steering Groups approve abbreviations  This listing will be reviewed annually

Abbreviation used Full Terminology

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Appendix 3

Electronic Record Keeping Audit Tool

Please note this is an electronic record keeping audit tool which is an Excel document. You will be able to access this tool on the intranet – http://luna.smhsct.local/documents/policies-a-z/r/4989-record-keeping-standards-clinical-rka-audit-tool/file

Record Keeping Audit Tool 2016/17 - Guidance

Enter audit results directly into the blue tab for the respective quarter.

The red tab will populate with the percentage compliance.

Based on your review of the records and the percentage compliance please complete the report tab identifying areas of good practice and any areas in need of improvement.

An action plan will need to be completed for all Amber or Red criteria, please add this to the action plan tab.

Sample Size: A total of 30 records per quarter, this can be split over weeks, months or audited as a whole at the end of each quarter. Where services/teams do not have 30+ records the whole case load will be audited each quarter.

Submission of completed Audits: To: Groups Clinical Effectiveness Coordinator and pathway Matron. Q1 7th July Q2 7th October Q3 7th January Q4 7th April

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For any queries or assistance please contact: Pathway Matron (i.e. MH, CYPF, Forensic, Community, Assessment & Treatment) Groups Clinical Effectiveness Coordinator/Facilitator

Reference documents: Record Keeping Policy include link to policy on the intranet Clinical Audit Policy include link to policy on the intranet

Information Governance Alliance (IGA) - Records Management CoP for Health & Social Care 2016 include link to CoP on the intranet

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Appendix 4

Record Keeping Audit Process Map

Manager (ward, unit, team) is responsible for ensuring the Record Keeping Audit is

completed for their area of responsibility

Record Keeping Audit is undertaken as per guidance on the electronic audit tool and the electronic tool is completed

Results and Action plan is to be completed by the Auditor and Manager

Completed Audit Tool to be submitted to: Pathway Matron and Clinical Effectiveness Coordinator/Facilitator by the deadline date (see guidance on the audit tool).

Clinical Effectiveness Coordinator/Facilitator will review the results and action plan for individual teams and group wide and provide Themed analysis

Themed analysis to be provided to the Matron, relevant group meeting for review and monitoring, and included quarterly in the groups Quality and Safety Report

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Appendix 5 Mental Health Division Clinical Abbreviation List Approved – September 2018 Abbreviation used Full Terminology 6 CIT 6 Item Cognitive Impairment Test ACE Addenbrooke’s Cognitive Examination ADL Activities of Daily Living BD Twice Daily BFT Behavioural Family Therapy BGM Blood Glucose Monitoring BP Blood Pressure CBT Cognitive Behavioural Therapy CPA Care Programme Approach CPMS Clozaril Patient Monitoring Service CTO Community Treatment Order CT SCAN Computer Tomography Scan CxR Chest X-Ray DBT Dialectical Behaviour Therapy DNAR Do Not Attempt to Resuscitate DSQIID Dementia Screening Questionnaire for Individuals with Intellectual Disabilities ECG Electrocardiogram ECT Electroconvulsive Therapy EEG Electroencephalogram EGFR Estimated Glomerular Filtration Rate FBC Full Blood Count FPG Fasting Plasma Glucose GPCOG General Practitioner Assessment of Cognition Hx History IMI Intra Muscular Injection IV Intra Venous LAI Long Acting Injection LFT Liver Function Tests MANE Morning Mcg Micrograms Mg Milligrams MHA Mental health Act MHRT Mental Health Review Tribunal MMOLS Millimoles MMSE Mini Mental State Examination MRI scan Magnetic Resonance Imaging Scan NOCTE Night time UTI Urinary Tract Infection OD Once Daily PET scan Positron Emission Tomography Scan PRN Pro Re Nata (As Required) PD Personality Disorder Px Prescription QDS Four Times Daily RPG Random Plasma Glucose RUDAS Rowland Universal Dementia Assessment Scale SFT Solution Focussed Therapy WRAP Wellness Recovery Action Plan TDS Three Times Daily TFT’s Thyroid Function Tests TTO’S Tablets to take out TYM Test Your Memory U&E’s Urea and Electrolytes YOD Young Onset Dementia

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Policy Details

Title of Policy Clinical Record Keeping Policy

Unique Identifier for this policy BCPFT-CLIN-POL-13

State if policy is New or Revised Revised Care Record Keeping – Standards and Previous Policy Title where applicable Practice Policy Category Clinical Clinical, HR, H&S, Infection Control etc. Executive Director Executive Director of Nursing, AHPs and whose portfolio this policy comes under Governance Policy Lead/Author Matron for Learning Disabilities Job titles only Committee/Group responsible for the Information Governance Steering Group approval of this policy Month/year consultation process June 2016 completed * Month/year policy approved April 2017

Month/year policy ratified and issued April 2017

Next review date October 2019

Implementation Plan completed * Yes

Equality Impact Assessment completed * Yes

Previous version(s) archived * Yes

Disclosure status ‘B’ can be disclosed to patients and the public

* For more information on the consultation process, implementation plan, equality impact assessment, or archiving arrangements, please contact Corporate Governance

Review and Amendment History Version Date Details of Change Minor amendments in response to recent RCA to ensure staff 2.1 Apr 2017 document the details and involvement of any other agencies involved 2.0 Oct 2016 Full policy review and new policy format Policy for the new organisation BCPFT; alignment of policies 1.0 Nov 2012 following TCS

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