Proper Record-Keeping & Management: A British Perspective

Ensuring accurate, clear, and confidential records is crucial for any organisation. Let's explore common pitfalls, management best practices, and the legal rights surrounding record access in the UK.

Common Errors in Record-Keeping

Maintaining records requires diligence and attention to detail. Here are prevalent mistakes to avoid:

• Timing: Omitted timestamps or delayed entries.
• Legibility: Unreadable handwriting.
• Completeness: Missing entries or ambiguous abbreviations.
• Communication: Omission of names in phone call records.
• Correction: Use of Tippex and concealing errors.
• Authentication: Absence of signatures.
• Patient Details: Missing or inaccurate patient/client information.
• Terminology: Unprofessional language or vague phrases.
• Accuracy: Mixing opinions with facts or relying on unattributed sources.

Record Management Best Practices

Proper record management goes beyond just accurate record-keeping. It encompasses how records are stored, accessed, and eventually discarded.

Security and Retention

Records should be held securely and confidentially, presented when required, and retained only for the necessary duration. The National guidance offers minimum retention periods for various record types, which should align with your organisation's Records Management Policy.

Individuals' Rights to Access Information

Three key legislations in the UK define an individual's rights to access information:

1. Freedom of Information Act: Provides insight into public bodies' operations and decisions.
2. Environmental Information Regulations 2004 (EIR): Grants access to environmental data.
3. Data Protection Act: Allows individuals to request a copy of their data held by organisations.

It's pivotal to understand that:

• Recorded information should always uphold professionalism.
• Third parties might access the information you record.
• Information access shouldn't be denied due to potential embarrassment.

Responding to Access Requests

Legal compliance is paramount. For Freedom of Information requests, you must provide a response within 20 working days. Under the Data Protection Act, individuals, including service users and employees, can access their recorded information and seek clarifications, with requests answered within 40 days.