Health Record Keeping
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”. “All staff have a legal and professional responsibility for records they create or use”. NHS Code of Practice 2006
Principles of Good Record Keeping
Confidentiality Confidentiality is central to trust between doctors and patients. Identifiable information should not disclosed for purposes other than healthcare without individuals explicit consent. Under common law, you are allowed to disclose information if it will help to prevent, detect, investigate or punish serious crime or if it will prevent abuse or serious harm to others. Keep disclosures to the minimum necessary.
Access
Disclosure
Information Systems
Legislation CQC- this is the body that ensures that clinical excellence is maintained throughout the NHS. GMC-Good Medical Practice guidelines Clinical Records Keeping Standards Policy 08086
Case Note Tracking Tracking of notes is essential to support the function of seeking and retrieval of notes in a timely manor. Health Records must be diligently tracked in and out of all locations. Health records outside of the library should only be on loan for 3 weeks. If a health record is required for loan for a purpose other than a clinic appointment or TCI and it is not in the record library, the requestor/ borrower is responsible for obtaining those notes.
Buff / Lilac Folder (Original Notes) Case Note Definitions Pink/White (Temporary Folder)
Procedure for the Format of Patients Records First Spine – on plastic clip Identification sheet Records Held sheet Clinical writings & reports Maternity booklets & Care Pathway documentation (one plastic wallet- episode) Correspondence (ie. Discharge summaries & consent forms ) Documents relating to complaints or litigation are not filed in case notes Second Spine (front) – on Elastic Second Spine (back) – On Elastic Nursing notes -One sealable plastic wallet per episode Brown manila sealable envelope -Burns & plastic hand X-rays,oral X-rays Photographs
Policies
Litigation Litigation can be very expensive to the NHS. The legal bill so far this year is 8 billion pounds (Enough to open a new hospital.) Medical litigation attracts high media attention If the patient’s notes do not contain the necessary information then litigation against the NHS cannot be defended.
Audit Findings A recent audit has highlighted the need for greater vigilance in the areas of :- Ensuring any alterations are corrected with a single line, dated, timed and signed All entries in history sheets are printed with a name, designation and are timed When consultant responsibility changes for a patient, the new consultant’s name is recorded along with the agreed date and time of transfer of care Discharge arrangements are clearly stated
Thank you If you have any queries regarding notes please contact the health care records library service