Standard 3.5 Record Keeping
Good record keeping is essential to ensure that people receive effective and safe care. Health services must ensure that all records are maintained in accordance with legislation and clinical standards guidance.
The health service will need to consider the following criteria for meeting the standard:
- Paper and electronic clinical record quality is improved through adoption of the Academy of Medical Royal Colleges standards for the clinical structure and content of patient records.
- Clear accountability for record keeping supports effective clinical judgements and decisions.
- There is effective communication and sharing of information between members of the multi-professional healthcare team and the patient.
- Record keeping supports clinical audit, research, allocation of resources and performance planning.
- Evidence shows how decisions relating to patient care were made.
- Identification of risks enables early detection of complications.
- Record keeping supports the delivery of services, patient care and communications.
- Records are designed, prepared, reviewed and accessible to meet the required needs.
- Records are stored securely, maintained, are retrievable in a timely manner and disposed of appropriately.
- Records are accurate, up-to-date, complete, understandable and contemporaneous in accordance with professional standards and guidance; and shared when appropriate.
- People’s personal records are regularly updated and available to them. To ensure confidentiality, they are kept secure and comply with the Data Protection Act 1998.
- Care, treatment and decision making is supported by structured, accurate and accessible patient records documenting the conversations between people and health professionals and the resulting decisions and actions taken and reflects best practice founded on the evidence base.
Standard 3.5 Record Keeping Supporting Guidance