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Record-keeping guidance

Your clinical record is the primary source of evidence used to provide effective ongoing care to your patients and to account for your actions and decisions.

An overview of record-keeping

A good record will provide evidence of the nature of conversations you have had with your patient, the extent of any exam you have performed, what treatment was provided and your clinical reasoning for the decisions you have made.

Did you know?

  • Physiotherapy staff have a professional and legal obligation to keep an accurate record of their interaction with patients.
  • If you use a smart phone to text or call patients, that stores their name and contact details, this counts as ‘keeping records’.

  • You must be registered with The Information Commissioner’s office if you or your organisation keep patient records, unless a legal exemption applies.
  • Your duty to share information is as important as your duty to maintain patient confidentiality (Caldicott Review in England 2013).
  • The use of SNOMED CT is now being driven by health policy and within NHS England its use is mandated.
  • All record keeping is governed by The Data Protection Act 1998.
  • Being able to make and maintain records is a requirement of your HCPC registration.

  • Keeping detailed records is a requirement of your CSP membership.

Keeping records

Records can be made in any format that allows the standard of care provided to be permanently recorded.

The format you use may depend on the context of your service and whether you work closely in teams where others may need to see your records.

Key points to remember when making records:

The information must be clear to another health professional/the patient (including the use of short forms)

File 194975Written records should be:

  • legible and written in permanent ink
  • signed at the end of each entry
  • paginated, including date and time of consultation
  • amendments should be dated, timed, signed and the original entry still clearly visible.

Electronic recording systems should be able to:

  • show who has made the record
  • show revisions or amendments
  • lock the notes

You should review the standards for the clinical structure and content of patient records, compiled by the Health and Social Care Information Centre (HSCIC) in 2013, and supported by the CSP. They outline generic clinical record headings and the information that should be recorded under each heading across the medical professions.

Clinic letters electronic or digital records are acceptable provided all elements of the assessment, intervention, judgment and treatment are recorded.

Pre-printed templates for record keeping can be useful. They may save time by avoiding repetitive writing, they can act as a prompt to clinicians and they can be useful in standardising the expectations of a reasonable assessment.

If you’re a registered physiotherapist or student, you need to make your own records; as a student your records must be countersigned by your supervisor. If you’re a support worker your records will need to be made according to your local policies and procedures’.

Your employer's responsibility

The organisation or practice employing you must keep the clinical records securely on their premises. You must be given reasonable access to the records you create and must not take records with you when you leave one place of work and move elsewhere.

If your practice is challenged, or your patient has a concern about the care they’ve received, your records are an essential part of the review process. If you’ve failed to keep a reasonable record this may make it more difficult to account for events and/or professional decisions.

Sharing records

File 139619

Your duty to share information is as important as your duty to maintain patient confidentiality. The Caldicott Review in England 2013 highlighted that safe and appropriate sharing in the interests of the individual’s direct care should be the rule, not the exception.

You must share information with other health professionals directly involved in the patient’s care in order to give the best possible advice and treatment. You don’t need the patient’s written permission to do this, but you should always seek to ensure that your patient is aware of the communication you have with other health professionals. The patient has the right to prevent you sharing information.

Access to records

All patients have a right under The Data Protection Act (DPA) to see a copy of their health records. Requests to see records must be made in writing and processed within 40 days. You should provide a copy of the records, not the original, and a reasonable fee may be charged (see record-keeping guidance PDF at the bottom of this page).

File 194967Where a third party, eg a solicitor or an insurance company requests a copy of a patients records you must have the patient’s written consent to release the records before you do so.

Where the police require access to records they will advise you if you can obtain the patient’s written consent. They will provide alternative legal authority to release the records if it’s not appropriate for you to contact the patient.

Relatives of patients have no right to see a living patient’s records without the patient’s written consent unless the relative holds a Power of Attorney or other legal authority for the patient.

The right to confidentiality of medical records continues after a patient’s death. Requests to access a deceased patient’s medical record should be made under the Access to Medical Records Act 1990 to the data processor. Permission may be considered either by legal authority and/or the Executors of the deceased’s Estate.

Storage, retention and destruction of records

File 194968You must store your records in accordance with the DPA, ie, in a lockable cabinet.

Retention schedules vary according to the type of record (see record-keeping guidance PDF at the bottom of this page) but, in general, for those with capacity is usually eight years from the date of last treatment for adult records, and for children eight years after their 18 birthday or until 25 years of age. Other types of records may need to be stored indefinitely.

Once the retention period has expired you must securely destroy and dispose of the records.

 

 

 

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Additional Information

Publication Date

November 2016

Last reviewed

November 2016

Author(s)

CSP

Price

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