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There are some common errors when keeping records and these include:

  • Times omitted
  • Illegible handwriting
  • Lack of entry in the record
  • Abbreviations which were ambiguous
  • Record of phone call which omitted the name of the recipient
  • Use of Tippex and covering of errors
  • No signature
  • Absence of information about the patient or client
  • Inaccuracies, especially of the date or omission of date
  • Delay in completing the record, sometimes more than 24 hours elapsed before the records were completed 
  • Record completed by someone who was not actually there 
  • Inaccuracies of name, date of birth and address 
  • Unprofessional terminology 
  • Meaningless phrases 
  • Opinion mixed up with facts
  • Reliance on information from neighbours without identifying the source

It is not only good record keeping that is important but also good record management. Records should be held securely and confidentially, made available when needed and kept no longer than is necessary.

The National guidance outlines minimum retention periods for different types of record, which should be outlined in your organisation’s Records Management Policy. You should be aware of the policy for the management and destruction of records that you work with.

There are three regimes that enable individuals to access information that we hold. The Freedom of Information Act gives rights to individuals to have information about how public bodies function and make decisions. Under this Act, individuals have a right to be told whether we hold particular information and to be provided with a copy. Similarly, they have a right to access environmental information under the Environmental Information Regulations 2004 (EIR), and under the Data Protection Act.  

Under these acts, individuals can request a written copy of information about themselves held by an organisation.  Although some information is exempt from disclosure, in the majority of cases information will be disclosed. In recording information, you should be aware that:

  • All information must be recorded in a professional manner
  • Third parties may have a right to access information that you record and should be written with that assumption
  • We cannot withhold access to information just because it would embarrass either individuals or the organisation

If a Freedom of Information requests is received you must respond to the request, and ensure that is answered, within 20 working days.

Under the Data Protection Act, individuals service users and employees, have certain rights about the way information about them is used. These include the right to see information that is recorded about them and to have any part of it they do not understand explained. The request must be answered within 40 days.