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Healthcare record keeping policy

Contents

1 Policy summary

This policy is relevant to all individuals who create, access and manage health care records, outlining several legislative requirements concerning how records should be kept and maintained.

There are key principles that employees must demonstrate when creating, accessing, and managing records that are listed for attention in the appendices.

The policy outlines the key steps when creating a record, the information to be obtained and the minimum requirements from trust employees.

All employees should have relevant training to ensure that they meet the requirements outlined in the policy.

There are several other trust policies that are relevant to good record keeping that are referenced and hyperlinked throughout.

2 Introduction

Rotherham Doncaster and South Humber NHS Trust (the trust) must ensure that all healthcare records are created, accessed, managed, and disposed of in accordance with national standards and professional accountability; and are compliant with legal, operational and information governance requirements.

The trust must conform to several legislative requirements, regulations, and standards (opens in new window) that outlines the management of records. These can also be found in the trust’s records management policy.

Healthcare records are an integral part of healthcare practice which is generated on, or on behalf of, all the health employees involved in all aspects of patient care (for example, the care, service and treatment provided) and may need to be accessed by the various employees involved in care delivery.

Healthcare records are generated in a variety of ways including electronic, paper and media storage.

The trust’s healthcare records are primarily held on the electronic patient record (EPR) system which has safeguards in place to protect the integrity, accessibility, and accuracy of the record. The purpose of a healthcare record is to facilitate the care, treatment, and support of patients. To ensure that healthcare records are created in a consistent and professional manner the ‘health care record keeping standards’ (see appendix D) should be always adhered to.

3 Purpose

The aim of this policy is to ensure that all healthcare records generated by health employees are contemporaneous, accurately reflect high standard patient care and support the delivery of evidence-based practice.

This policy outlines the roles, responsibilities, and accountability of trust employees in complying with guidance, legislation, and best practice for keeping records.

4 Scope

This policy covers all types of healthcare records accessed by the trust.

This policy applies to:

  • all employees working for or on behalf of the trust, including contracted third parties, agency employees, locums, students or trainees, secondees, employees from partner organisations with approved access, visiting employees, researchers, companies providing other services to the trust, for example, information technology (IT) and all volunteers
  • any trust healthcare records held, maintained, and managed by third parties under contract to the trust

For further information about responsibilities, accountabilities and duties of all employees, please see appendix A.

5 Procedure or implementation

5.1 Quick guide to health care records

5.1.1 Consent

  • Obtain consent from the patient to access relevant personal information.
  • Refer to relevant Mental Capacity Act (MCA) guidance where there are concerns regarding capacity.

5.1.2 Generic information

  • Ensure the relevant information is captured on the generic information template in the EPR.
  • Keep personal information up to date.

5.1.3 Minimum content

  • Ensure the relevant content is captured using the appropriate templates in a timely way:
    • assessment of need
    • care plan
    • assessment of risk

5.1.4 Timely entries

  • Complete records as soon as possible after and event.
  • If there is not time to make a full entry, record the pertinent information including medication changes and risk.
  • When making a retrospective entry, ensure this is clearly stated including the reason for the delay.

5.1.5 Letters

  • Make the patient aware of their right to receive information about their care and treatment.
  • Consider the individual accessible need of the patient their family and, or carer.
  • Ensure the patient receives the relevant information in line with their personal choices.

For the principles of effective healthcare record keeping, please see appendix B.

5.2 Creating an electronic healthcare record

When creating an EPR for a patient, several unique patient identifiers will be downloaded automatically from the national summary care records system (Spine).

However, consent must be obtained from the patient to access the following information via the summary care record:

  • allergies or sensitivities or hypersensitivities
  • medication

Further guidance regarding consent is available at Information Commissioners Office (opens in new window).

Where the patient lacks mental capacity to give consent, a decision to access additional information should be made in their best interests. See MCA Mental Capacity Act 2005 policy for further guidance or refer to Gillick competency and Fraser guidelines (opens in new window) for patients under the age of 16.

5.3 Minimum data and assessment requirements

There is a minimum data set required for all patients who use trust services, located in the generic information template within the EPR and should be inputted during registration. This information including the patient address must be updated checked and updated regularly during the episode of care.

Following an assessment of a patient, the assessment and outcomes must be recorded in the EPR on the approved templates that have been provided.

The trusts minimum requirements for EPR record are:

  • an assessment of need
  • a personalised care and treatment plan, this may be referred to as goals in some departments which links to the assessed needs of the patient
  • an assessment of risk relevant to the care being delivered, including risk mitigation and management plan
  • contemporaneous records of healthcare contacts or events which are recorded in the appropriate data entry template and, or questionnaire
  • records, where possible, should ensure that patient and, or significant other views are reflected and that the care being offered is personalised

The trust has published guidance (staff access only) (opens in new window) to optimise the use of the EPR and encourage best practice. Employee must familiarise themselves with and follow these materials.

Where there are paper records, the healthcare professional is personally responsible and accountable for compliance.

5.4 Delays in completing contemporaneous records

It is expected that all health employees complete records as soon as possible after an event, within 24 hours or less if your local working instructions or arrangements, or key performance indicators’ (KPI’s) require this. All agile workers (those with remote access to the EPR via a digital device) should always be expected to update pertinent aspects of the healthcare record at the time of the visit or when appropriately safe to do so, for example, administration of medicines and specific risks associated with safety.

Any delay entering information into the healthcare records will be based on the health professional’s clinical decision at that time, utilising their knowledge of the patient, the situation, and circumstances.

This decision needs to take into consideration the following:

  • any risks to patient safety or the safety of others (including employees), should there be a delay in entering information into the healthcare record
  • any risks to future clinical decision making if pertinent information is not made available
  • delays or blockers in accessing other services due to incomplete healthcare records

Where a delay in entering information has occurred, the record must include a reference to the fact that it has been entered retrospectively including a reason for the delay.

5.5 Paper healthcare records

Whilst most healthcare records generated will be held on the EPR system, paper records are still in existence within the trust. Employees should refer to the records management policy for further information relating to storing, tracking, accessing, retention and disposal.

5.6 Copying letters to patients

From 1 August 2016 onwards, all organisations that provide NHS care and, or publicly funded adult social care are legally required to follow the accessible information standard (opens in new window). The Standard sets out a specific, consistent approach to identifying, recording, flagging, sharing, and meeting the information and communication support needs of patients, service users, carers and parents with a disability, impairment, or sensory loss.

Patients have the right to request or receive information held about them under the Data Protection Act 2018 (opens in new window) and the Freedom of Information Act 2000 (opens in new window). This means if patients, consent or agree, letters written about them by one health professional to another should be copied to the patient, or where appropriate, parent, legal guardian or specified other. Further guidance is available from ROAN information sheet 23, quality improvement, best practice for clinical letters (opens in new window).

It is the responsibility of health professional to make patients aware of the fact that they are entitled to receive copies of any letters or documents which relates to them. The patient will need to make an informed preference whether they wish to receive clinician’s letters or not. They will be given a choice on what information they want, who from, the address to which it will be sent and what format (if appropriate). The patient preference should be documented in the generic information template in their EPR and reviewed annually or when the health professional and patient deem it appropriate.

6 Training implications

  • The training needs analysis can be found in the mandatory and statutory training policy.
  • All new employees will be made aware of the policy via the induction process and a copy will be available on the website.
  • All employees must ensure that they familiarise themselves and adhere to the content of this policy and any subsequent changes. Managers must actively ensure that employees who create, manage, transfer, retain or dispose of healthcare records undertake appropriate training opportunities.
  • All employees handling, accessing, or populating healthcare records will receive record keeping training on induction to the organisation. Training will be appropriate to the individual employee’s role, regularly assessed and refreshed to ensure employees remain appropriately skilled and knowledgeable over time. A minimum of a 3 yearly update is required via the Healthcare record keeping resource (staff access only) (opens in new window).
  • Ongoing review of the employees record keeping will be captured and evidenced as part of their supervision.
  • Please note there are a number of EPR guides, videos and system updates available by accessing the clinical systems page (staff access only) (opens in new window) on the intranet.

7 Equality impact assessment screening

To access the equality impact assessment associated with this policy, please follow the link: EIA.

7.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

7.1.1 How this will be met

All employees, contractors and partner organisations working on behalf of the trust must follow the requirements of this policy and other related policies, particularly those relating to information governance. All health employees must also meet their own professional codes of conduct in relation to confidentiality.

7.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

7.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005).

8 Links to any other associated documents

All the documents listed below cover various aspects of record keeping, maintenance and storage and employees should familiarise themselves with:

9 References

10 Appendices

10.1 Appendix A Responsibilities, accountabilities, and duties

10.1.1 The trust

The trust has a ‘duty of care’ and a ’duty of confidentiality’ to ensure that all aspects of healthcare record keeping are properly managed. The trust must adhere to the legislative, statutory, and good practice guidance requirements relating to healthcare records management.

10.1.2 The chief executive

The chief executive has overall accountability and responsibility for healthcare records within the trust. This function is delegated to the executive medical director and the executive director of nursing and allied health employees, who are responsible for driving high quality standards of healthcare record keeping.

10.1.3 The trust executive medical director

The trust’s executive medical director (and trust Caldicott guardian) plays a key role in ensuring that NHS and partner organisations comply with current national guidance and relevant legislation regarding the handling and safeguarding of ‘patient identifiable information’. The Caldicott guardian will advise employees on matters relating to the management of patient identifiable information, for example where issues such as the public interest conflicts with duties such as maintaining confidentiality.

10.1.4 Senior managers

Senior managers of the trust are responsible for the quality of the healthcare records that are generated by all trust employees to ensure patient safety and quality service delivery.

10.1.5 Head of information management and business intelligence

Head of information management and business intelligence will advise the trust on how to maintain an efficient and effective patient information system, which complies with all the data collections required within the NHS.

10.1.6 The clinical audit team

The Clinical Audit team will support care groups through local place-based audit programmes and Tendable where requested.

10.1.7 All employees

All employees of the trust are responsible for any records which they create or use. This responsibility is established at, and defined by, the Public Records Act 1958. As an employee of the NHS any records created by an employee are public records. All employees must adhere to the relevant trust record keeping and records management policies. In addition, all clinical employees have a professional responsibility and accountability to comply with record keeping standards and protocols specific to their professional codes of conduct or practice, for example, nurses, midwives and nursing associates should refer to the Nursing and Midwifery Council Code for guidance on record keeping. Medical employees should refer to the General Medical Council (GMC) Good Medical Practice, Guidance for Doctors and Allied Health Employees should refer to the Health and Care Professions Council (HCPC) guidance.

10.2 Appendix B Principles of health care records

Accessible to all relevant employees to enable them to carry out their duties. Information must be stored in the correct areas in the EPR and entered via approved data entry formats where they exist.

Understandable, clear, and concise. Healthcare records must avoid the use of jargon and technical terminology as the patient or other employees must be able to read and understand what is written about them. Where health employees wish to use abbreviations, a trust approved list should be consulted in appendix E. Any term can be abbreviated within an individual entry as long as it is written in full the first time.

Factually accurate and relevant. Healthcare records must be concise, factual, and where possible include collateral evidence. Employees should avoid using personal opinions.

Secure. When accessing the electronic patient record, employees must ensure that this is done via smartcard and PIN number. Username and passwords should only be if there are issues with the smartcard software. Passwords and PIN numbers should not be written down or shared.

Employees must ensure that their computer screens cannot be seen by others who should not normally be privy to patient information which may require the use of a privacy screen or other suitable products. If for any reason the employee member needs to leave the computer screen, this must be locked.

Where an EPR exists, paper records should only be used in the event of system failure and all temporary records must be uploaded into the EPR once the system is restored.

10.3 Appendix C Monitoring arrangements

10.3.1 Employee practice standards or competence

  • How: Where an audit is not available on Tendable the assessment and management of professional competency will be monitored at a local level through the following arrangements:
    • monthly audit of patient records (an example template is available in appendix F)
    • individual employee supervision or PDR processes
  • Who by: line managers.
  • Reported to: Care group quality meetings.
  • Frequency: Monthly.

10.3.2 All complaints received

  • How: Complaint’s procedure.
  • Who by: Service managers or matrons in conjunction with the Complaints team.
  • Reported to: The relevant care group leadership and quality group.
  • Frequency: Quarterly.

10.3.3 Tendable 

  • How: Ongoing regular audits will be undertaken using Tendable by care groups to ensure that ongoing record keeping is of the required quality. This will help to inform local audit programmes and to measure the impact of actions taken, supporting improvement activity.
  • Who by: Ward or team managers, service managers and other clinical employee depending on the audit type and identified or Tendable trained employee will undertake these audits.
  • Reported to: Care group quality meetings.
  • Frequency: Ongoing regular audits will be undertaken using Tendable by care groups to ensure that ongoing record keeping is of the required quality. This will help to inform local audit programmes and to measure the impact of actions taken, supporting improvement activity.

10.4 Appendix D Health care record keeping standards

Top tips to support our improvement work to ensure good quality records, care and treatment plans and clinical risk assessments.

10.4.1 What makes a good quality record

  • Right login, are you logged in as yourself?
  • Right record, are you in the correct patient record? Double check before you start adding an entry Right module or unit, are you in the right module or TPP unit?
  • Right place, are you in the correct template in the record for this piece of information?
  • Right time:
    • are the entries or detail in the correct order chronologically where possible?
    • have they been entered in a reasonable timeframe after contact with the patient? If not, have you explained why in the record?”
  • Right detail included, for example:
    • allergy status
    • next of kin
    • language
    • documented fully that a letter hash as not been shared (check generic information tab)
    • staff members and other attendees documented names and job roles in full
    • actions and reasoning clear and relevant to the
      entry
  • Right wording used:
    • wording appropriate, clear and factual and relevant
    • opinion, jargon and speculation free
    • free from abbreviations, or where used, to be written in full in first instance
    • enough information to make the entry clear and to the point
    • avoid confusion (staff or patient)
  • Right communication identified:
    • nominated person to contact if not the patient themselves-carer or family member
    • declined to share information with carer or family members, is this clear to other staff?
    • have you checked the demographics? Address, contact numbers etc.
    • alerts or flags
    • correct format identified

10.4.2 Care and treatment planning

  • Ensure your patient has a current care and treatment plan, depending on the service you work in this will be captured using core ‘care plan’ or ‘goal” functionality or via a bespoke “template”.
  • Please ensure you routinely produce care and treatment plans collaboratively with your patients capturing their views and preferences in the narrative-avoid jargon and abbreviations.
  • Have you offered a copy of the care and treatment plan to your patient?
  • For services who create care and treatment plans you should complete the ‘RDASH care plan consent, patient or family or carer Template’ within the care plan folder on the clinical tree, to indicate the patient has agreed the care and treatment plan and whether they have accepted or declined a copy.

10.4.3 Clinical risk assessment

  • Ensure your patient has a up to date clinical risk assessment.
    • the current process supports a stepped approach to risk assessment, it means all patients are expected to have a screening risk assessment, with further enhanced assessment only required if and where areas of higher risk are noted?
  • Remember when you have completed your risk assessment you should save as final version, which can’t be edited.
  • Ensure your risk assessment is individual to your patient and is co-produced with your patient, their carer and wider MDT where appropriate, it should include:
    • meaningful activities to manage risk
    • positive risk management
    • has a strengths-based approach which is realistic and achievable

In summary, our record keeping should be GREAT:

  • good quality
  • relevant and individualised
  • evidence patients voice
  • accurate and complete
  • timely

10.5 Appendix E Trust approved abbreviations

Abbreviations
Abbreviation Definition
A&E Accident and emergency
ABPI Ankle brachial pressure index
ACE Angiotensin-converting enzyme
Ace III Addenbrookes cognitive examination III
ACP Advanced care practitioner
ACT Acceptance commitment therapy
ACTH Adrenocorticotropic hormone
A-DES Adolescent dissociative experiences scale
ADHD Attention deficit hyperactivity disorder
ADL(S) Activities of daily living
ADRT Advance decision to refuse treatment
AED Anti-epileptic drugs
AF Atrial fibrillation
AHP Allied health profession
AIDS Acquired immunodeficiency syndrome
AKI Acute kidney injury
ALP Alkaline Phosphatase
ALT Alanine Aminotransferase
AMH Adult mental health
AMHP Approved mental health professionals
AN Antenatal
ANP Advanced nurse practitioner
APTT Activated partial thromboplastin time
ARMS At risk mental state
ASD Autism spectrum disorder
ASQ Ages and stages questionnaire
AST Aspartate Aminotransferase
AP Attendant propelled
AWOL Absent without leave
BA Behavioural activation
BAPEN British association for parenteral and enteral nutrition
BER Beyond economic repair
BGT Balloon gastrostomy tube
BI Best interests
BiPAP Bi-level positive airway pressure
BMI Body mass index
BNF British National Formulary
BNP B-type natriuretic peptide
BO Bowels open
BP Blood pressure
BPH Benign prostatic hyperplasia
BPM Beats per minute
BPSD Behavioural and psychological symptoms of dementia
C&YP Children and young people
C. diff Clostridium difficile
CAMHS Child and adolescent mental health services
CAT Cognitive analytical therapy
CBT Cognitive behavioural therapy
CCE Child criminal exploitation
CCG Clinical commissioning group
CCN Children’s community nurse
CCP Cyclic citrullinated peptide
CDOP Child death overview panel
CEDS Children’s eating disorders
CEOP Child exploitation and online protection
CFT Compassion focused therapy
CHC Continuing healthcare
CHD Coronary heart disease
CIC Children in care
CIN Child In need
CKD Chronic kidney disease
CMHT Community Mental Health team
CNN Community nursery nurse
CNS Clinical nurse specialist
COPD Chronic obstructive pulmonary disease
COSHH Control of substances hazardous to health
COVID-19 Coronavirus disease
CP Child protection
CPA Care programme approach
CPAP Continuous positive airway pressure
CPR Cardio-respiratory resuscitation
CQC Care Quality Commission
CRIES Child revised impact of events scale
CRP C-reactive protein
CRT Cognitive rehabilitation therapy
CSCI Continuous subcutaneous infusion
CSE Child sexual exploitation
C-section Caesarean section
CSPCT Community Specialist Palliative Care team
CSPR Child safeguarding practice review
CST Cognitive stimulation therapy
CSU Catheter stream urine sample
CT Computed tomography
CWP Children’s well-being practitioner
CYPs Children and young people’s services
D&A Drug and alcohol service
DASH Domestic abuse, stalking and honour based violence
DBT Dialectical behavioural therapy
DBTH Doncaster and Bassetlaw Hospital
DDP Dyadic developmental psychotherapy
DHR Domestic homicide review
DMBC Doncaster Metropolitan Borough Council
DN District nurse
DNA Did not attend
DNACPR Do not attempt cardio-respiratory resuscitation
DoLS Deprivation of liberty safeguards
DRI Doncaster Royal Infirmary
DVLA Driving and vehicle licensing agency
DVT Deep vein thrombosis
ECG Electrocardiogram
ED Emergency department
EDD Expected date of delivery
EDTA Ethylene-diamine-tetra-acetic acid
EEG Electroencephalogram
eGFR Estimated glomerular filtration rate
EHCP Education health care plan
ELR Elevating leg rests
EMDR Eye movement desensitisation reprocessing
EOLT End of Life team
EPIC Electric powered indoor wheelchair
EPIOC Electric powered indoor outdoor wheelchair
ESR Erythrocyte sedimentation rate
EUPD Emotionally unstable personality disorder
EVOLVE Local authority multi agency child exploitation service
FACE FACE risk assessment
FBC Full blood count
FEP Free erythrocyte protoporphyrin
FGM Female genital mutilation
FII Fabricated or induced illness
FP10 Prescription form
FSW Family support workers
FT Family therapy
GAD2 Generalized anxiety disorder 2 questions
GAD5 Generalized anxiety disorder 5 questions
GCSF Granulocyte colony stimulating factor
GGT Gamma-glutamyl transferase
GMC General medical council
GP General practice or practitioner
Hb Haemoglobin
HbA1C Haemoglobin with glucose irreversibly bound
HCAI Healthcare acquired Infection
Hct Haematocrit
HDL-cholesterol High-density lipoprotein cholesterol
Hep B Hepatitis B virus
Hep C Hepatitis C virus
HIV Human immunodeficiency virus
HNA Health needs assessment
HOOF Home oxygen order form
HPV Human papillomavirus
HR Heart rate
HR(S) Hour(s)
HRT Hormone replacement therapy
HTT Home Treatment team
HV Health visitor
ICB Integrated care board
ICPC Initial child protection case conference
ICS Integrated care system
IDDSI International dysphagia diet standardisation Initiative
IDVA Independent domestic violence advisors
IHTT Intensive Home Treatment team
IMCA Independent mental capacity advocate
IMHA IMHA independent mental health advocate
Imms Immunisations
INR International normalized ratio
IPC Infection prevention and control
IPOC Individual plan of care
IPT-A Interpersonal therapy for adolescents
IPU Inpatient unit
IR Immediate release (medications)
IR1 Incident reporting
IRO Independent review officer
IT Information technology
JTAI Joint targeted area inspection
LA Local authority
LAB Laboratory
LAC Looked after child
LADO Local authority designated officer
LASER Light amplification by stimulated emission of radiation
LD Learning disability
LDL-cholesterol Low-density lipoprotein cholesterol
LFD Lateral flow device
LFT’s Liver function tests
LI-CBT Low intensity cognitive behavioural therapy
LLR Lessons learnt review
LOS Length of Stay
LPD Low profile device
LPoA Lasting power of attorney
LPS Liberty protection safeguards
LTBI Latent tuberculosis infection
LTC Long term condition
LUNSERS Liverpool University neuroleptic side effect rating scale
MACE Multi agency child exploitation meeting
MAOI Monoamine-oxidase inhibitor
MAPPA Multi-agency public protection arrangements
MARAC Multi-agency risk assessment conference
MASH Multi-agency safeguarding hub
MBT Mentalization based therapy
MCA Mental Capacity Act
MCA1 Record or evidence of assessment of capacity
MCA2 Record or evidence the best interest decision (where a patient lacks capacity)
MCV Mean cell volume
MDR TB Multi drug resistant tuberculosis
MDT Multi-disciplinary meeting
MHA Mental Health Act
MHLT Mental Health Liaison team
MHRA Medicines and healthcare products regulatory agency
MI Myocardial infarction
MMR Measles, Mumps, and Rubella
MND Motor neurone disease
MoCA Montreal cognitive assessment
MRI Magnetic resonance imaging
MRSA Methicillin-resistant Staphylococcus aureus
MS Teams Microsoft Teams
MSE Mental status examination
MSU Midstream specimen of urine
MUST Malnutrition universal screening tool
Na Sodium
NBM Nil by mouth
NCEPOD National confidential enquiry into patient outcome and death
NEPSY-II A developmental neuropsychological assessment, version 2
NEWS National early warning score
NEWS2 National early warning score 2
NG Tube Nasogastric tube
NHS National Health Service
NICE National Institute for Health and Care Excellence
NIV Non-invasive ventilation
NLaG Northern Lincolnshire and Goole NHS Foundation Trust
NLC North Lincolnshire council
NMP Non-medical prescriber
NN Nursey nurse
Nocte Every night
NoF Neck of femur
NRT Nicotine replacement therapy
NSAID Non-steroidal anti-inflammatory drug
NSCAP Northern School of Child and Adolescent Psychotherapy
O2 sats Oxygen saturations
OC Obsessions and compulsions
OCD Obsessive compulsive disorder
OOH Out of hours
ONS Oral nutritionalsupplements
OPAT Outpatient parenteral antibiotic therapy
OPD Outpatient department
OPMH Older peoples mental health
OT Occupational therapist
PA Physicians associate
PACE Playfulness, acceptance, curiosity and empathy
PALS Patient advice and liaison service
PCR Polymerase chain reaction
PE Pulmonary embolism
PEG Percutaneous endoscopic gastrostomy
PET scan Position emission tomography
PHE Public Health England
PHQ2 Patient health questionnaire 2 questions
PHQ9 Patient health questionnaire 9 questions
PHSIO Physiotherapy(ist)
PICU Psychiatric intensive care unit
PIP Personal independence payment
PIPOT Persons in a position of trust
POON’s Paediatric outreach oncology nurses
PPE Personal protective equipment
PPI Proton pump inhibitor
PSA Prostate-specific antigen
PTH Parathyroid hormone
PTSD Posttraumatic stress disorder
PTT Partial thromboplastin time
PWB Personal wheelchair budget
QOF Quality and outcomes framework
RA Rheumatoid arthritis
RAG Red, amber, green
RBC Red blood cells
RCADS Revised child anxiety and depression scale
RCPC Review child protection conference
RDaSH Rotherham, Doncaster and South Humber
ReSPECT Recommended summary plan for emergency care and treatment
RFS Refeeding syndrome
RGN Registered general nurse
RIDDOR Reporting of injuries, diseases and dangerous occurrences regulation
RMBC Rotherham Metropolitan Borough Council
RMN Registered mental health nurse
RNLD Registered learning disabilities nurse
RR Respiration rate
RSV Respiratory syncytial virus
S(number) Section (insert relevant section number) for example S2, equals section 2
SAB Safeguarding adult board
SALT Speech and language therapy
SAR Safeguarding adult review
SCH Sheffield Children’s Hospital
SENCO Special educational needs and disability coordinator
SEND Special educational needs and disability
SGH Scunthorpe General Hospital
SI Serious incident
SIADH Syndrome of inappropriate anti-diuretic hormone
SIDS Sudden infant death syndrome
SLE Systemic Lupus Erythematous
SMS Short message service
SN Staff nurse
SOAD Second opinion appointed doctor
SOMRAP  Subjective objective medication risk analysis plan
SOP Standard operating procedure
SP Self-propelled
SPA Single point of access
SPC Summary of product characteristics
SPOC Single point of contact
SpR Specialist registrar
SSN Special school nurse
ST Specialty trainee (rotational training doctor)
StN Student nurse
STOMP Stopping over medication of people with a learning disability, autism or both
STPP Short term psychodynamic psychotherapy
T/C Telephone Call
TAF or TAC Team around family or child
TAP Thorax, abdomen and pelvis
TB Tuberculosis
tel Telephone
TENS Transcutaneous electrical nerve stimulation
TIA Transient ischemic attack
TNA Trainee nurse associate
TRFT The Rotherham Foundation Trust
TRS Trauma and resilience service
TSH Thyroid stimulating hormone
TTO To take out
TV Television
TXT Text
U&E(s) Urea and electrolytes
UBB Unborn baby
UTI Urinary tract infection
VTE Venous thromboembolism
VTS Vocational training scheme (rotational training doctor, GP)
WAIS Wechsler adult intelligence scale, fourth UK edition
WBC White blood cells
WCC White cell count
WISC Wechsler intelligence scale for children
WS Wells score
XDR TB Extensively drug resistant tuberculosis
YMARAC Young-persons multi-agency risk assessment conference
YOS Youth offending service

Further abbreviations available in the safe and secure handling of medicines manual and the records management policy.

10.6 CPR Appendix F Health care record keeping auditCQC

Healthcare record keeping audit
Criteria Where is this located Yes or no
Are any abbreviations in the patient record included within the approved abbreviation list attached to the updated healthcare record keeping policy Appendix E of the healthcare records policy
  • Yes
  • No, action required or discussion with supervisor
Has it been recorded in the patient record whether the patient has any sensitivities or allergies, or no known allergies recorded. Note, this should not be blank Located under the sensitivities and allergies node in the clinical tree
  • Yes
  • No, action required or discussion with supervisor
If prescribed medication is their evidence of medication monitoring for side effects, templates on SystmOne to be completed where available to the required timeframes Located in specific medication template (Lithium or antipsychotic for example) or evidenced within tabbed journal under medication related entries
  • Yes
  • No, action required or discussion with supervisor
Is there a care plan or a plan of care which captures the patients’ identified needs and care and treatment plans Located in the care plan folder under the clinical tree
  • Yes
  • No, action required or discussion with supervisor
Does the care plan have a date for when this will be reviewed or when this will be completed by? Located in the care plan folder under the clinical tree
  • Yes
  • No, action required or discussion with supervisor
Is there evidence that the patient has been involved in planning their care plan or plan of care? Located in the core care plan functionality under the clinical tree as agreement by patient in the drop-down menu
  • Yes
  • No, action required or discussion with supervisor
Does the patient consent to relatives or carers being involved in their care? Located in the care plan consent template within the care plan folder under the clinical tree
  • Yes
  • No, action required or discussion with supervisor
Where appropriate and consent given is there evidence that carers, family or significant others were involved in the care plan or plan of care? Located in the core care plan functionality under the clinical tree as agreement by respective person in the drop-down menu
  • Yes
  • No, action required or discussion with supervisor
Is there evidence that the patient was offered a copy of their care plan or given information about what would be provided by the service? Located in the care plan consent template within the care plan folder under the clinical tree
  • Yes
  • No, action required or discussion with supervisor
Is there evidence that a risk assessment has been fully completed? For example:

  • FACE (mental health services including CAMHS)
  • HoNoS
  • cluster tool (mental health)
  • multifactorial (falls risk assessment)
  • MUST
  • pressure ulcer
  • service specific risk assessments
Located in respective risk template in SystmOne. As some of these might be questionnaires, only the title of the document will be visible in the tabbed journal, but full details can be viewed in the questionnaire’s node under the clinical tree
  • Yes
  • No, action required or discussion with supervisor
Is there evidence that the risk assessment takes into consideration any historical risks where known? Respective question within respective template
  • Yes
  • No, action required or discussion with supervisor
Is there a date for when the risk assessment will be reviewed? Respective question within respective template
  • Yes
  • No, action required or discussion with supervisor
Is there evidence that the risk assessment was reviewed by this date or sooner if risks changed? Respective question within respective template
  • Yes
  • No, action required or discussion with supervisor
Is it documented that the patient wishes to receive communication from the service? Located in the generic information template (red triangle on SystmOne toolbar) under the Accessible information tab
  • Yes
  • No, action required or discussion with supervisor
Is it documented how the patient wants to be communicated with from services?

  • letter
  • telephone
  • text (SMS)
  • email
Located in the generic information template (red triangle on SystmOne toolbar) under the Accessible information tab
  • Yes
  • No, action required or discussion with supervisor
Is there evidence of communication being sent to the patient? Located in the tabbed journal or communications and letters node under the clinical tree
  • Yes
  • No, action required or discussion with supervisor
Is it documented that the patient needs communication or information in line with the accessible information standard? Located in the generic information template (red triangle on SystmOne toolbar) under the Accessible information tab
  • Yes
  • No, action required or discussion with supervisor
Is it documented if the patient wants communication in a different language other than English? (including British Sign Language) Located in the generic information template (red triangle on SystmOne toolbar) under the Accessible information tab
  • Yes
  • No, action required or discussion with supervisor
Are all service specific templates fully completed on SystmOne? Service specific templates to be identified by service leads
  • Yes
  • No, action required or discussion with supervisor
Has an entry been made in line with service specific requirements:

  • per shift
  • per appointment
  • per contact
  • following any incidents or intervention
Evidence in tabbed journal of service specific templates such as SOMRAP, handover template
  • Yes
  • No, action required or discussion with supervisor

Discuss an action plan and any training needs required as a result of this audit, who will do what by what timeframe and when will this be reviewed.

Specific measurable achievable realistic timely, ACTION PLAN (example below):

  • clinician 1 will book on risk assessment training
  • clinician 1 will be shown risk assessment template on SystmOne
  • clinician 1 will update risk assessment with supervisor support, including carer involvement and discuss with the patient and give a copy to the patient by 2 June 2023. To review full caseload in next supervision

Document control

  • Version: 4.5.
  • Unique reference number: 473.
  • Approved by: Clinical polices review and approval group.
  • Date approved: 5 September 2023.
  • Name of originator or author: Head of information quality.
  • Name of responsible individual: Director of health informatics.
  • Date issued: 2 February 2024 (minor amendment).
  • Review date: 31 August 2025.
  • Target audience: All employees with responsibility for clinical record keeping.

Page last reviewed: March 21, 2024
Next review due: March 21, 2025

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