1. Health Record Keeping

2. 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

3. Principles of Good Record Keeping

5. Confidentiality

6. Access

7. Disclosure

8. Information Systems

9. Legislation

10. Case Note Tracking

11. Policies

12. Extracts from HPC/NMC hearings where Registration Numbers were either suspended or cancelled

13. 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
Recording of care rounds is accompanied by a printed name
Complete set of observations are in place with an accurate score in place
Allied Health Professional (AHP) entries have specified type of AHP they are

14. Thank You
If you have any questions regarding patient notes please speak to your line manager
Please ensure you fill in and submit the intranet form so this training can be recorded onto your training record