Good Record Keeping

Records management is the efficient and systematic control of the creation, receipt, maintenance, use and disposal of records. This includes paper records as well as online data.

Good records management and compliance is everyone’s responsibility.

All records go through a series of phases:

Creation
Use
Maintenance and management
Review
Retention
Disposal decisions and actions

These all present opportunities for positive and proactive records management to help assure effective ‘good record keeping’ practice.

Good Practice

Poor quality information presents a risk to patients, service users, staff members and the organisation. If you are uncertain about any of the good practice raised, talk to your line manager to improve your understanding.

Record as events occur

Record information while the event, care or otherwise is still fresh in your mind.

Complete

Ensure all patient or service user information is included so that records can be shared and accessed effectively. Remember to include the NHS number if available.

Free from duplication

Before you create a new record, make sure that one doesn’t already exist.

Quick and easy to locate

Save records in a secure place that are easy to find.

Compliant with procedures

Ensure that records are stored safely and securely and can be quickly located when requested.

Certain simple actions can ensure that you comply with the principles of the Data Protection Act. Your organisation will have policies and procedures and can give you training to help ensure good governance of personal information.

It is important that records are full, accurate, dated and timed. They should distinguish between service user records, your opinions and any information provided by others. This is particularly applicable to making decisions about a child or young person's safety or welfare.

Be accurate

· Enter accurate information into records and ensure that the information is kept up-to-date

· Give individuals the opportunity to check and confirm the details held about them

· Avoid creating duplicate records

Information Disposal

Stick to your organisation’s policy and procedures for the disposal of personal information.

Seek advice from your line manager, ICT department or technology provider when disposing of information held on digital assets for example, laptops and smartphones.

All devices, such as laptops, must be disposed of by your ICT department or provider.

Any personal data must be treated as confidential and securely disposed of. This includes secure disposal of paper records in locked confidential waste bins. This will ensure that official papers containing personal data are securely shredded.

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