The Chartered Society of Physiotherapy The Chartered Society of Physiotherapy

Basket

View your shopping cart.

Audit tool: Record keeping and information governance

Details for quality assurance in record keeping and information governance can be found below. Please download the audit tool from the bottom of the page.

Part 1A: Data collection from service user records

Records include the following components:

  • Started at the time of the initial contact
  • Written immediately after the contact with the service user or before the end of that working day
  • Include a reference in each entry to the date and time of treatment or advice
  • Include a reference to the date and time that the entry into the record was made
  • Are legible, factual, consistent and accurate such that service users and other health professionals can understand the content
  • Are attributable to the individual completing them
  • Provide evidence of the care planned, the decisions made, the care delivered and the information shared
  • Identify problems that have arisen and the action taken to rectify them
  • Provide evidence of actions agreed with the service user including consent to treatment and/or consent to disclose information)
  • Are written, wherever appropriate, with the involvement of the service user
  • Use standard coding techniques and protocols for electronic records where appropriate
  • Short forms used are included in a glossary describing the allowable abbreviations and their meaning

Part 1B: Data collection from organisational policies and procedures

There are organisational policies for records including the following components:

  • Are started at the time of the initial contact
  • Are written immediately after the contact with the service user or before the end of that working day
  • Include a reference in each entry to the date and time of treatment or advice
  • Include a reference to the date and time that the entry into the record was made
  • Are legible, factual, consistent and accurate such that service users and other health professionals can understand the content
  • Are attributable to the individual completing them
  • Provide evidence of the care planned, the decisions made, the care delivered and the information shared
  • Identify problems that have arisen and the action taken to rectify them
  • Provide evidence of actions agreed with the service user (including consent to treatment and/or consent to disclose information)
  • Are written, wherever appropriate, with the involvement of the service user
  • Use standard coding techniques and protocols for electronic records where appropriate
  • a locally agreed short forms glossary
  • disclosure of information
  • service user access to records, including charges for viewing or receiving a copy of a health record 

There are policies for:

  • the retention of records
  • the secure storage of records while current so that they can be easily retrieved
  • the secure storage of records once they are no longer current
  • the disposal of records in accordance with statutory requirements
  • identification of who has storage and access rights over the record
  • access to records by service users and others
  • Records are kept in accordance with relevant legal and regulatory requirements
  • A policy for IT (Information Technology) and data security which is updated annually. 

There is:

  • a signature book to ensure physiotherapy team members can be recognised and traced by their signature, job title and work area or other identifiable information
  • information available to ensure that the service user is aware of their right to access their records
  • a glossary of short forms describing the allowable abbreviations and their meaning
  • a process for destroying service user records in a secure manner after the (lapse of the) required time 

There is a procedure to ensure

  • Members are aware of their responsibilities under the Data Protection Act (1998)
  • Members comply with local health informatics/ IT security policies
  • Members are clear of the standards in place for governing their record keeping practice
  • Audit of record keeping planned and undertaken annually to monitor compliance with relevant legislation and ensure best practice guidance is being upheld
  • The results of audit are disseminated and recommendations made for action
  • Systems are configured to meet information governance standards around maintaining the security and confidentiality of service user identifiable data, including encryption of emails and use of mobile/portable device
  • There is evidence that action is taken as a result of the outcomes of audit

Part 2: Service user feedback

I was given information on

  • How to access my physiotherapy records

Links

Back to top