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High standards of record keeping promotes the welfare of service users by enabling a high standards and continuity of care. It also promotes better communication and sharing of information between members of a multi-disciplinary care team, giving an accurate account of care planning and delivery. Another benefit is that is has the ability to detect problems, such as changes in the service user’s condition at an early stage
Good quality records should:
• Be factual, consistent and accurate, written in a way so that the meaning is clear
• Be recorded as soon as possible after an event has occurred, providing current information on the care and condition of the service user
• Be recorded clearly and in such a manner that the text cannot be erased or deleted without a record of the change
• Be recorded in such a manner that any justifiable alterations or additions are dated, timed and signed or clearly attributed to a named person in such a way that the original entry can still be read
• Be accurately dated, timed and signed, with the signature printed alongside the first entry where it is a written record, or attributed to a named person for an electronic record
• Not include abbreviations, jargon, meaningless phrases, irrelevant speculation or subjective or offensive statements
• Be legible and readable when photocopied or scanned
• Be written, where possible, with the involvement of the service user
• Be consecutive
• Identify risks and/or problems that have arisen and the action taken to rectify them
• Provide clear evidence of the care planned and decisions made, the care delivered and the information shared
Records should also:
• Use standard coding techniques and protocols
• Provide evidence of action agreed with the service user including consent to treatment and consent to disclose information
• Be secure and confidential
• Be in line with locally agreed policies
It is worth noting that although information should be as factual as possible, where relevant personal opinions are contained within a record or shared with other colleagues or agencies they should be clearly stated as such.
It is important to note also that where information is not recorded, for example, of an assessment, visit or any other action, the assumption will be made that that it did not take place.
Finally, a record or any communication we make is only as good as the information it contains. Information needs to be of good quality if it is to be fit for purpose and used and shared effectively. Good quality information is complete, accurate, relevant, accessible and timely.
You have a responsibility to inform an appropriate person, either within your organisation or another agency, if you come across information which you know to be inaccurate or where you have shared information that you subsequently realise is inaccurate.