CUH

Good record keeping guidance for staff

at Addenbrooke's

It is vital all staff maintain up-to-date and accurate information relating to symptoms, diagnosis and treatment in patient health records for many reasons. First and foremost, the quality of current and future patient care is dependent on it. Inaccurate record keeping can result in delays and possible harm to the patient.

 

Style

  • Each entry must be dated and signed with staffs first and last name and professional designation (or by using a self-inking stamp)
  • Write clearly and legibly and use black ink
  • Use objective, precise language and terminology that the patient will be able to understand. Avoid ‘casual’ remarks, personal opinions regarding the patient and abbreviations that may not be understood by a non-professional

 

Content

  • Entries must be completed as soon as possible
  • Record current information on the care and condition of the patient
  • Record the source of referral of the patient (the general practitioner, hospital consultant)
  • Record any problems that have arisen
  • Record evidence of any planned or delivered care
  • Record any decisions made
  • Record relevant conversations with friends or family
  • Avoid any unnecessary gaps
  • Record the actions agreed with the patient at the time of discharge

 

Mistakes

  • Draw a single line through incorrect entries
  • Initial and date the error
  • Make a note in the margin that the entry was made in error and note what the correct entry should be
  • Do not use correction fluid

 

To avoid mistaken identities:

  • The patient's name, hospital number and NHS number must be recorded on every page

 

Consent forms

  • Record any information that has been given to the patient before they give consent; this then proves ‘informed’ consent
  • Patients must sign the consent form after the treatment has been discussed with the doctor

 

Adverse Reactions

  • Record any adverse reactions or problems including drug allergies on the prescription charts, case-notes and head-sheets/treatment sheets. Record all allergies and alerts, such as latex, on the Alert form (note: there must always be an Alert sheet at the front of every patient case-note folder)

 

Confidentiality and finding notes

  • Case-notes must not be removed from the hospital or send original case-notes to other hospitals
  • The medical records tracking system on the HISS computer system must be used to track the location of the notes – for example, when case-notes are taken from one area of the hospital to another.

 

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On this website:

 

> Patient Advice & Liaison Services (PALS)

 

> Making a complaint

 

> Freedom of information

 


 

On other sites:

 

> NHS Care Records Service

To improve the service and quality of your care a new computer network is being developed nationally that will phase out the need for paper and film records. The network will hold your entire patient record to allow Hospitals, GP’s and chemist’s secure access to your health records to improve information sharing across the NHS.

 

> The Information Commissioner

 

> NHS Connecting for Health

 

> Ministry of Justice

 

> Department of Health