The above list is not exhausted Process for Health Records Yearly Head of Information/Caldicott the creation Administration Medical Committee of records Audit Records Record Record Keeping Yearly Head of Information/Caldicott keeping Audit Medical Committee meets Records acceptable standards Security and Audit of Annual Information Information/Caldicott confidentiality Departments Plan Governance Committee – of records check no PII left Manager / out on desks, Head of locked filing Healthcare cabinets, doors, Records codes are changed, fax machines Appendix A: Record Keeping Essential Elements Where there are local variations it is the responsibility of the healthcare professional to ensure that they are aware of and adhere to these variations. Essential Elements All records must be kept on Trust authorised stationery. • The name of the person about whom the record is made must appear along with the • NHS number Hospital number or any relevant reference numbers on each page. Where health record sheets have not been pre-printed, patient labels will be used • e.g. on all history sheets, Nursing Assessments and Diagnostic Test Results. A clear and logical format must be used. • Only black ink should be used. • Judgmental or inferential statements are not recorded. • All entries must be signed with a signature not initials. A block capital of the name must • appear with all signatures. Accurately date and time every entry with day, month, year and 24 hour clock • A key should be shown where initials are used. • Records that have been written up contemporaneously cannot later be torn up or • discarded. No Record = No Contact, as the activity cannot be corroborated. • Should be free from any unknown abbreviations. Any abbreviations used must be in • accordance with guidelines issued by the relevant professional bodies. Left and right should always be written in full • Never use abbreviations for making derogatory comments about the patient • All document filing is the responsibility of the individual, service or department in • possession of the case notes at the time of the episode concerned and need to ensure that all loose documents are affixed in the records prior to being returned to the Health Records library. In the event that the records are returned to the library before such
The above list is not exhausted Process for the creation of records Health Records Administration Audit Yearly Head of Medical Records Information/Caldicott Committee Record keeping meets acceptable standards Record Keeping Audit Yearly Head of Medical Records Information/Caldicott Committee Security and confidentiality of records Audit of Departments – check no PII left out on desks, locked filing cabinets, doors, codes are changed, fax machines Annual Plan Information Governance Manager / Head of Healthcare Records Information/Caldicott Committee Appendix A: Record Keeping Essential Elements Where there are local variations it is the responsibility of the healthcare professional to ensure that they are aware of and adhere to these variations. Essential Elements • All records must be kept on Trust authorised stationery. • The name of the person about whom the record is made must appear along with the NHS number Hospital number or any relevant reference numbers on each page. • Where health record sheets have not been pre-printed, patient labels will be used e.g. on all history sheets, Nursing Assessments and Diagnostic Test Results. • A clear and logical format must be used. • Only black ink should be used. • Judgmental or inferential statements are not recorded. • All entries must be signed with a signature not initials. A block capital of the name must appear with all signatures. • Accurately date and time every entry with day, month, year and 24 hour clock • A key should be shown where initials are used. • Records that have been written up contemporaneously cannot later be torn up or discarded. • No Record = No Contact, as the activity cannot be corroborated. • Should be free from any unknown abbreviations. Any abbreviations used must be in accordance with guidelines issued by the relevant professional bodies. • Left and right should always be written in full • Never use abbreviations for making derogatory comments about the patient • All document filing is the responsibility of the individual, service or department in possession of the case notes at the time of the episode concerned and need to ensure that all loose documents are affixed in the records prior to being returned to the Health Records library. In the event that the records are returned to the library before such
Health%20Care%20Records%20Policy%20Final%2020120905.docx