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Record keeping v1
 

Record keeping v1

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Clinical Skills day 23.1.13 Leicester Peepul centre

Clinical Skills day 23.1.13 Leicester Peepul centre

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    Record keeping v1 Record keeping v1 Presentation Transcript

    • Record Keeping By Sharon Leverton
    • Definition A health record is defined in section 68(2) Data Protection Act 1998 as:-• Information relating to the physical or mental health or condition of an identifiable individual.• Records being made by or on behalf of a health professional in connection with the care of an individual.
    • Quiz!Q1. Is your work diary classed as a health carerecord?A. YESQ2. As an Health care worker are the recordsthat you create deemed as public records?A. YES
    • True Or FalseQ3. Everyone working for or with the NHS whorecords, handles, stores or otherwise comes acrossinformation has a personal common law duty ofconfidence.A. TRUEQ4. The Data Protection Act 1998 now placesstatutory restrictions on the use of personalinformation, including health information.A. TRUE
    • Delegation & Countersigning Standards• Records created by non registered staff must be countersigned at the end of each episode of care or at least 4 monthly for Level 1 & level 2 patients• For complex patients the caseload holder retains the responsibility for all delegated tasks• In these cases the caseload holder should make the decision on the frequency of countersigning
    • What Are The Benefits Of Good Record Keeping?• Easier continuity of care• Documentary evidence of services delivered• Communication and sharing of information between members of the multi-professional healthcare team• Identify risks and enabling early detection of complications• Supporting clinical audit, research, allocation of resources & performance planning• helping to address complaints or legal processes
    • What Makes A Good Health Care Record?• Factual, Consistent, Accurate• Consecutive & Chronological• Written up as soon as possible• Legible Handwriting• Dated, Timed & Signed• Free of jargon• Non judgemental• Involve patients• Evidence of care planned, care delivered and information shared
    • Quotes Taken From Healthcare Records• “By the time he was admitted, his rapid heart had stopped and he was feeling much better”.• “Her husband seems surprisingly sensible”.• “Mr X thinks more of his dog than his wife”• “Between you and me, we ought to be able to get this lady pregnant”.• “The lab test indicated abnormal lover function”.
    • How Can You Avoid Similar Mistakes?• Read back your own records and those of others• Audit records in line with policies and procedures
    • What Is The Main Barrier To Maintaining Accurate Records?• No paper• Not being able to use a computer• Time• Not knowing what to write• Not being familiar with standardised medical abbreviations
    • What Are The Consequences of poor record keeping?• Poor patient care• Lack of continuity of care• Mistakes• Complaints• Scrutiny of documentation• Disciplinary procedures• Criminal proceedings• Death
    • When Things Go Wrong• Clinical supervision• Notes review• Incident reporting• Governing body support and advice
    • http://www.nmc-uk.org/Hearings/Hearings-and-outcomes/http://www.hpc-uk.org/complaints/hearings/
    • http://www.justice.gov.uk/downloads/burials-and-coroners/guide-charter-coroner.pdf
    • Remember! “IF IT IS NOT WRITTENDOWN, IT WAS NOT DONE”
    • Please complete and hand in all your feedback forms. Thank you for your time! Sharon Leverton