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 Version 2.1 April 2017 Clinical Record Keeping Standards Policy 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 Version 2.1 April 2017 2 Clinical Record Keeping Standards Policy 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 Version 2.1 April 2017 3 Clinical Record Keeping Standards Policy 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) Version 2.1 April 2017 4 Clinical Record Keeping Standards Policy 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,