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People who use services provide us with information about themselves to help us provide appropriate care. Keeping a proper record of this information provides us with an accurate account of the contact an individual had with our service.
In addition to service user information, we also record information for the purpose of managing the organisation and the services we provide. Keeping proper records of this information provides us with an accurate account of the way the organisation conducts its business.
Information may be recorded in a variety of places, for example, we record information in, Staff records for example, references, record of sickness, DBS check.
Organisational records for example incident forms, complaints, risk, finance.
Patient/service user records for example, care record, risk assessments and minutes or notes of meetings diaries notebooks, letters/memos, faxes and emails. Finally, office computer systems for example, Excel Word, Access.
The complete record may be made up of information from a number of different sources. For example, a service user record may include a history of treatment and care given, letters between health and/or social care professionals, test results, x-rays etc. Organisational records may contain notes of meetings, correspondence in the form of emails and letters, records of telephone calls, papers outlining issues and decisions taken etc.
Any information that forms part of a record, should be stored together as a coherent document. For example, if a file is in paper format and a relevant piece of information is recorded electronically, such as in a letter or an email, then the letter or email should be printed out and stored with the paper file. If it isn’t possible to hold the information in the same format then it should be referenced appropriately such that it is obvious to the reader that other information exists.
All of the above information, both personal and organisational, enables us to manage the organisation for the benefit of service users and ensures we are accountable in the work that we do and the services we provide.
Keeping good records of information enables us to:
• Make effective decisions
• Provide an explanation for decisions made or actions taken
• Provide continuity of care and continuity of service provision
• Review the quality of service provided and promote high standards
• Provide internal and external accountability
• Investigate any complaints
• Guard against fraud and protect the rights and assets of the Trust and individuals
The responsibility for record keeping is with every one and good practice but the organisation has a statutory responsibility to keep proper records and the Chief Executive is responsible for ensuring that individuals maintain proper records. You are responsible for the day to day records you create and use. It is a requirement of working for the organisation that you keep proper records of the work that you do.