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Record keeping v1


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Clinical Skills day 23.1.13 Leicester Peepul centre

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Record keeping v1

  1. 1. Record Keeping By Sharon Leverton
  2. 2. 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.
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. 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”.
  9. 9. How Can You Avoid Similar Mistakes?• Read back your own records and those of others• Audit records in line with policies and procedures
  10. 10. 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
  11. 11. 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
  12. 12. When Things Go Wrong• Clinical supervision• Notes review• Incident reporting• Governing body support and advice
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  16. 16. Please complete and hand in all your feedback forms. Thank you for your time! Sharon Leverton