clinical and social care record keeping policy · 3 definitions 6 – 7 4 roles and...

Gloucestershire Care Services NHS Trust and Gloucestershire County Council Clinical and Social Care Record Keeping of 21

Clinical and Social Care Record Keeping Policy This is a joint Gloucestershire Care Services NHS Trust and

Gloucestershire County Council Adult Social Care policy

Integrated care teams (ICTs) are staffed by both Gloucestershire County Council (GCC) and Gloucestershire Care Services (GCS) personnel. This creates unique policy conditions in that two policies will continue to be required initially. The integrated GCC/GCS Clinical and Social Care Record Keeping policy will co-exist alongside the GCC Record Keeping policy.

This integrated GCC / GCS policy applies to everyone employed by GCS and to people employed by GCC who work in the ICTs in partnership with GCS.

The GCC Record Keeping policy applies to anyone employed by GCC outside of the ICTs (for example within the GCC Learning Disability Service). It does not contradict anything within the GCC / GCS integrated policy but includes additional detail in some instances which GCC staff employed within the ICTs may find helpful.

Organisation Gloucestershire Care Services NHS Trust

Gloucestershire County Council

Document reference: CP 30 Version: 4 1 Ratified by: Integrated Governance &

Quality Committee Adult senior management team

Date ratified: March 2015 Originator/author: Sarah Warne Deborah Greig Responsible committee/individual:

Clinical Policy Group

Executive lead: Director of Nursing Date issued: April 2015 Review date: January 2018

THIS IS A CONTROLLED DOCUMENT

Whilst this document may be printed, the electronic version maintained on the Gloucestershire Care Services NHS Trust and Gloucestershire County Council

intranets is the controlled copy. Any printed copies of this document are not controlled.

It is the responsibility of every individual to ensure that they are working to the most current version of this document.


DOCUMENT CONTROL SHEET

Purpose of document:

Health records produced by clinicians working within Gloucestershire Care Services NHS Trust and social care records produced by practitioners within Gloucestershire County Council Adult Social Care will provide accurate, current and comprehensive information that will adhere to the standards for Record Keeping laid down within this policy. This integrated policy explicitly states the responsibilities of health and social care professionals relating to the standard of clinical and social care record keeping required within both organisations.

Dissemination: The Policy will be communicated to staff via line managers following the approved processes within each organisation. The policy will be made available on each organisation’s intranet and it will also be highlighted in team meetings. Information on who to contact for access to the policy from outside Gloucestershire Care Services NHS Trust is available on the internet. The policy can be accessed by the public on the Gloucestershire County Council website.

Scope:

This policy applies to all staff who have reason to access and contribute to a clinical or social care record (including bank, locum and agency staff. Scope within Gloucestershire County Council is limited to staff working within integrated care teams (ICTs) but includes individuals and commissioned services authorised by Gloucestershire County Council to carry out adult social care functions within or on behalf of the ICTs.

Review: This document will be reviewed after 3 years or sooner if legislation or practice change dictates.

This document supports:

Audit Commission (1999), Setting the Record Straight: A Review of Progress in Health DH (2006) Records Management; NHS Code of Practice HSC 1999/053, For the Record: Managing Records in NHS Trusts and Health Authorities, HSC 1998/153, Using Electronic Patient Records in Hospitals: Legal Requirements and Good Practice, NHSE (1999), The Protection and use of Patient Information – guidance from the Department of Health, Department of Health Nursing & Midwifery Council (2009), Guidelines for Records and Record Keeping, London NMC July 2009 The Data Protection Act 1998 The Health Professions Order (2001) The Medical Defence Union (2001), ‘Can I see the records’, Clinical Notes- disclosure and patient access update of 1996 version NHSLA standard 1.8 Information Governance Toolkit The Freedom of Information Act 2000 The Data Protection (Subject Access Modification) (Social Work) Order 2000 The Human Rights Act 1998 The Care Act 2014 The Caldicott principles

Key related This document must be used in conjunction with the following


documents:

organisational documents: Gloucestershire Care Services NHS Trust Records Management Policy Data Protection Policy Information Governance Policy Information Sharing Policy Mental Capacity Act Guidelines Mental Capacity Act; Deprivation of Liberty guidelines Consent Policy Email Policy Clinical Documentation Requirements Use of Abbreviations within a Clinical Record Signature List Internal Audit Report 2012/13 for Gloucestershire Care Services by PWC The following documents relate to service specific requirements which should be used in conjunction with this policy: CP 30a Safeguarding Children Record Keeping (v2) CP 30b Unscheduled Care Record Keeping (draft) Gloucestershire County Council Assessment and Eligibility policy Personal Budgets, Planning and Review policy Direct Payments policy Record Keeping Policy Scanning Policy Information and Records Management Policy Data Protection Policy Information Security Policy Portable Media Policy Information IT Access Policy Remote Working policy Email Acceptable Use policy Freedom of Information Policy Access to Personal Information Policy Disclosure of Service Personal Information to Third Parties Code of Conduct Gloucestershire Mental Capacity Act 2005 Multi-Agency Policy, Procedure and Guidance (May 2011)* Deprivation of Liberty Safeguards Interagency Policies and Procedures (March 2009) (Revised January 2012) Gloucestershire Safeguarding Adults Policy and Procedure October 2012 Promoting Choice: Positive Risk Management

Quality and Equality

Quality and Equality Impact Reviews have been completed and can be found at appendix 2

Consultation:

Wide consultation with version 3a. Changes for version 3b and 3c that relate to organisational change visual identity and format change not consulted for individual policies. Version 3c changes relating to external audit results consulted at Clinical Audit meetings and IGC. Version 3d changes to incorporate requirements for Gloucestershire County Council (GCC) consulted through GCC GAPS processes.

Financial implications:

There are no financial implications related to this policy.

http://www.gloucestershire.gov.uk/extra/mcapolicy

http://www.gloucestershire.gov.uk/extra/mcapolicy


Version Control Information Summary of Key Changes Previous Version

Archive Date Version 1 archived February 28th 2011. Please contact Clinical Developmen Administrator on 03004221753 if access required.

Version 2 Policy updated to: • Reflect current legislation. • Reflect current NHSLA requirements. • Reflect change to NHS Gloucestershire Care Services from

Gloucestershire PCT.

February 28th 2011

Version 3 Policy updated to • Reflect organisational change • Reflect recommendations from external audit findings to include

specific guidance on who should be conducting a record keeping audit or acting as a reviewer (5.12)

Sampling techniques and size of audit (5.12)

Version 4 Policy updated to: incorporate requirements for Gloucestershire County Council Adult Social Care staff operating within integrated care teams


Contents:

Section Page 1 Introduction 6 2 Purpose 6 3 Definitions 6 – 7 4 Roles and Responsibilities 7 – 8 5 Policy Guidelines

Policy Detail 5.1 The Purpose of Records 5.2 Key Features of Health and Social Care Records 5.3 Ethical Aspects of Health and Social Care Records. 5.4 Record Content. 5.5 Entries in Health and Social Care Records 5.6 Clinical Information. 5.7 Information Sharing 5.8 Electronic Media - Text Messaging. E mail, FAX 5.9 Records Management. 5.10 Confidentiality 5.11 Safeguarding 5.12 Audit

8 – 18

6 Consultation 19 7 Resources 19 8 Training 19 9 Implementation 19 10 Equality Impact 19 11 Quality Impact 20 12 Review 20 13 References, Bibliography and Acknowledgements 20

Appendix 1 GCSNHST Annual Audit Minimum Requirements 21

Abbreviations Used Within Document Abbreviation Full Description

GCC Gloucestershire County Council GCSNHST Gloucestershire Care Services NHS Trust GCCASC Gloucestershire County Council Adult Social Care Service

ICTs Integrated Care Teams SMART Specific, Measurable, Attainable, Realistic and Timely


1. Introduction 1.1 GCSNHST and GCCASC have entered into a working relationship to deliver

integrated services to adults. It is intended that ultimately there will be integrated records for mutual service users. Separate recording systems currently operate. The first stage of integration is represented in this policy which defines in a single document the record keeping controls of both GCSNHST and GCCASC for personnel working within integrated care teams. GCCASC staff may wish to refer to the GCC Record Keeping policy for more detail.

1.2 Clearly written records, which are both comprehensive and conform to the guidelines laid down by the relevant professional bodies will help to facilitate greater effectiveness of communication between health and social care professionals, other professional colleagues, clients/service users, their families and carers, thus assisting in the provision of a service which is efficient, responsive, high quality, and that maximises resources.

1.3 Neither organisation uses a single model for health and social care records, due to the diversity of service provision, however a number of key principles are described within the policy which underpin safe, effective record keeping. These principles include content, style and legal aspects. The principles apply across all care settings and apply to both manual and computer held records.

2. Purpose 2.1 Health and social care records produced by clinicians working within GCSNHST and

adult social care staff working within GCCASC will provide accurate, current and comprehensive information that will adhere to the standards for Record Keeping laid down within this policy.

2.2 In summary, Health and Social Care records will: • Contain information to identify the service user. • Be meticulous in chronological order and relate to an identified episode of care or

intervention. • Distinctly record assessment, planning, implementation, review and evaluation of

care and intervention. 2.3 This policy explicitly states the responsibilities of health and social care professionals

relating to the standard of clinical and social care record keeping required within both organisations.

3. Definitions 3.1 Health Record: The term ‘health record’ is defined by Section 68 of the Data

Protection Act 1998, and refers to any electronic or written record which: “Consists of information relating to the physical or mental health or condition of an individual, and has been made by or on behalf of a health professional in connection with the care of that individual”.

Health Professional is also defined by the Act and means any of the following: • a registered medical practitioner (a "registered medical practitioner" includes any person who is provisionally registered under section 15 or 21 of the Medical Act

1983 and is engaged in such employment as is mentioned in subsection (3) of that section.)

• a registered dentist as defined by section 53(1) of the Dentists Act 1984. • a registered optician as defined by section 36(1) of the Opticians Act 1989. • a registered pharmaceutical chemist as defined by section 24(1) of the Pharmacy

Act 1954 or a registered person as defined by Article 2(2) of the Pharmacy (Northern Ireland) Order 1976.

• a registered nurse, midwife or health visitor. • a registered osteopath as defined by section 41 of the Osteopaths Act 1993,


• a registered chiropractor as defined by section 43 of the Chiropractors Act 1994 • any person who is registered as a member of a profession to which the Health

Professions Order (2001) extends, • a clinical psychologist. Child psychotherapist or Speech and Language Therapist. • a music therapist employed by a health service body, and • a scientist employed by such a body as head of department.

Social Care Record: Any electronic or written record relating to GCCASC social care casework including all discussion and / or contact with, on behalf of or in connection with a service user, their family or carers.

4. Roles and Responsibilities 4.1 General Roles Responsibilities and Accountability GCSNHST and GCCASC aim to take all reasonable steps to ensure the safety and

independence of patients and service users to make their own decisions about their care, treatment and social care arrangements. In addition GCSNHST and GCCASC will ensure that; • All employees have access to up to date evidence based policy documents. • Appropriate training and updates are provided. • Access to appropriate equipment that complies with safety and maintenance

requirements is provided. Managers and Heads of Service will ensure that: • All staff are aware of, and have access to policy documents. • All staff access training and development as appropriate to individual employee

needs. • All staff participate in the appraisal process, including the review of competencies. Employees (including bank, agency and locum staff) must ensure that they; • Practice within their level of competency and within the scope of their professional

bodies where appropriate. • Read and adhere as appropriate to GCSNHST and GCCASC policy. • Identify any areas for skill update or training required. • Participate in the appraisal process. • Ensure that all care and consent complies with the Mental Capacity Act (2005).

4.2 Roles and Responsibilities specific to this document All GCSNHST and GCCASC Employees.

Every member of staff who generates, handles or processes paper or electronic health and social care records is responsible for: • Correctly filing documents they have received. • Reporting any incident or near miss relating to clinical record keeping that they

witness or are involved in. • Liaising with their managers regarding any incidents in relation to clinical record

keeping that require further investigation. • Ensuring they attend training as they require related to clinical record keeping. Health and Social Care Practitioners Each practitioner bears individual responsibility for: • Ensuring that their own record keeping meets the standards detailed in this policy,

and that laid down by the relevant professional body. • Recognising own areas of difficulty and seeking support. • Supporting annual audit activity and action planning • Ensuring that where students or non-professionally qualified staff under their

supervision or where staff acting on their behalf complete clinical and / or social care documentation that the standards detailed in this policy are met.


GCSNHST Ward, Department Managers / Team Leaders and GCCASC Managers. • Ensuring that clinical record keeping in their areas is of the standard defined in

this policy. • Ensuring that any incidents that arise with regard to clinical record keeping are

addressed and managed, and where required investigated through the recognised GCSNHST and GCCASC processes.

• Maintain an up to date signature list, reviewed yearly (GCSNHST only) • Ensure abbreviations used are contained on approved abbreviation list. • Undertake or support record keeping audit activity and action planning.

GCSNHST Matrons, Community Managers and Heads of Service and GCCASC Head of Adult Social Care and Managers

Have a duty to: • Ensure that a programme of audit occurs as detailed within this policy, and to

ensure that appropriate action is taken to address any identified required actions as a result of audit.

• Ensure that audit results and action plans are shared within the appropriate GCSNHST and GCCASC committee / forum.

• Introduce and monitor a list of acceptable abbreviations (ratified via clinical policies group or GCCASC Management Team) for use within a specified locality / speciality/service.

• Introduce and monitor a signature list for use within each ward, department or team that is reviewed yearly. (GCSNHST only)

GCSNHST Risk and Governance and GCCASC Managers • Receive and analyse incident forms in relation to clinical record keeping. • Identification and analyse trends. • Feedback and learning via the appropriate organisational channels. GCSNHST Locality Managers and GCCASC Managers • Have a duty to ensure the overall standard of clinical record keeping within their

area of responsibility meets the standard detailed within this policy. GCSNHST Clinical Quality and Development To: • Support professionals undertaking clinical record keeping audit when requested to

do so. • Provide educational support as requested relating to clinical record keeping. • Provide advice on clinical record keeping e.g. production of new documents. • Undertake ad hoc audit relating to the delivery of the clinical quality agenda. Caldicott Guardians • Reflect the service users interests regarding the use of service user identifiable

information • Ensure patient / service user identifiable information is shared in an appropriate

and secure manner. • GCC Commissioners of services are responsible for: • Ensuring that commissioned services authorised to create, maintain and / or hold

ICT social care records on behalf of GCC are aware of requirements to comply with this policy.

5. Policy Guidelines 5.1 The Purpose of Records. The purpose of records created by Health and Social Care professionals is to:


• Facilitate effective communication between service users and professionals and all agencies involved in the care / support of the individual and to ensure their safety.

• Provide accurate, current, comprehensive and concise information concerning the condition and care / support of the service user or client and associated observations.

• Provide a record of any problems that arise and the action taken in response to them.

• Provide evidence of assessment of need, care / support required, intervention by professional practitioners and service user, client or carer responses.

• Include a record of any factors (physical, psychological or social) that appear to affect the service user, client or carer.

• Record the chronology of events and the reasons for any decisions made. • Support standard setting, quality assessment and audit. • Provide a baseline record against which improvement, deterioration or social

change may be judged.

5.2 Key Features of Health and Social Care Records. In addition to fulfilling the purposes set out in 5.1 properly made and maintained records will: • Be made in a timely manner. • Identify factors which jeopardise standards or place the service user, client or

carer at risk. • Provide evidence of the need, in specific cases, for practitioners with special

knowledge and skills. • Aid service user or client involvement in their own care. • Provide evidence to answer possible complaints which may be made. • Be written, wherever possible, in terms which the service user or client will be able

to understand. • Be recorded for GCSNHST on approved documentation (insert link to GCSNHST

clinical records requirements) or for GCCASC within the GCC database system or on documentation derived from that database system.

5.3 Ethical Aspects of Health and Social Care Records. • A correctly made record honours the ethical concepts on which good practice is

based and demonstrates the basis of the professional and clinical decisions made. • A basic creed of records and record keeping is that those who make access and

use the records understand the ethical concepts of professional practice which relate to them. These will include, in particular, the need to protect confidentiality, to ensure true consent and to assist patients and clients to make informed decisions.

• The originator will ensure that the entry in a record that she or he makes is totally accurate and based on respect for truth and integrity.

5.4 Record Content. 5.4.1 The Health and Social Care records will contain information to identify the

service user. These records can be in paper or electronic format. Each Health Record will contain the following identification data: • NHS number (where available) • MRN (Hospital) Number or ICS Number (it is recognised that within certain

services such a Genito Urinary Medicine that a clinic specific number is used instead of MRN to protect confidentiality)

• Service Users name in full with title • Date of birth • Full address and postcode


• Ethnic Group as identified by the Service User • The existence of any information which could be of significance to the care of the

service user must be identified. If paper records are used, this will be reinforced by an ‘ALERT’ sticker placed in the appropriate box on the outside of the front cover with the detail of this information written by a clinician in the space provide on the INSIDE of the front cover

This relevant information may include: Allergy - including hyper-sensitivity reactions Diabetic or other medical condition Identification of patient having a similar name to another

Note: It is recognised that alert stickers are not in use in the community, and that not all the current community patient held records enable staff to record information within the front cover. In this instance staff must ensure Alert information is clearly visible on the front page of the patient held record.

Where an electronic record is used, some medical alerts will be visible automatically following entry of clinical record in assessment templates. These alerts will be shown in either the demographics box or the patient home screen. Where this doesn’t occur a reminder will need to be entered onto the patient record. An allergy will be recorded on the Sensitivities and allergies node and a note will be visible in the patient home screen. There is functionality in some SystmONe modules to ensure that the presence of a patient with a similar name is identified. However, extra care should always be taken to ensure that the patient is correctly identifiied.

Each Social Care Record will contain the following identification data:

• Service user PRN • Service user NHS number (where available) • Service user NI number (where available) • Service user name in full, title and preferred name • Date of birth • Full address and postcode • Ethnic Group as identified by the service user • Current information about potential risks to the service user, carer(s), staff or other

people. Where appropriate, this should be entered as a Case Warning notification on the GCC database and where relevant risk information communicated to GCSNHST in accordance with interagency protocols.

5.4.2 Health and Social Care records should contain the following identification data or be recorded as NOT KNOWN or NOT APPLICABLE

Health Records • Contact telephone number, to include full STD codes

(Home and work numbers if agreed by patient) • Gender • Next of kin or person with parental responsibility • Name and address of a person(s) to contact in an emergency by a member of the

Service (note: not all services have this provision within their record set) • GP- Name and Address or telephone number

Social Care Records: • Contact telephone number, to include full STD codes (Home and work numbers if agreed by service user) • Gender • Details of interested parties, for example GP, carer, holder of Lasting or Enduring

Power of Attorney, authorised person (for the purpose of direct payments) or other representative.


• The powers (property and financial affairs/ health and welfare/both) conferred by a Lasting or Enduring Power of Attorney must be specified.

Health and Social Care Records The following will be included if appropriate to the needs of the service/client: • Religion • The person’s key worker or named professional • The person’s first language • The person’s occupation/employment status • The child/young person’s school, nursery etc. (GCSNHST only)

5.5 Health records Where paper records are used:-

• Writing must be legible • Information must be recorded on appropriate official paperwork (Clinical

Documentation Requirements) and have, as a minimum 3 means of patient identification (usually full name, unique number either NHS or MRN, and date of birth) this includes continuation sheets. Wherever possible a computer generated label should be used

• All entries will be written / typed in permanent black ink, with the following 3 exceptions; o Operation records will be completed in red ink o Annotations made by pharmacy staff on medication administration sheets will

be completed in green ink. o Did not attend (DNA) patients / clients should be recorded in red ink. This will

allow the information to be clearly visible, enabling prompt contact with the individual if required e.g. if ongoing treatment will be affected.

• The first time an individual writes in a record the following information must be given – Printed Name, Signature, Designation and Initials. Once this information is recorded in the record then it is acceptable to use initials only for subsequent entries. An index of signatures, initials and professional status will be held at locally agreed locations for services within NHS Gloucestershire Care Services. A master signature list template is available at signature list. The signature index must be updated annually and a copy of the index must be kept in line with records management policy.

• Where name stamps are being used the entry must still be signed. Name stamps must only be used by the member of staff to whom they belong and they will be responsible for the content of the entry

• The date and time of each entry will be recorded • Any additions to existing information will be individually dated, timed and signed /

initialled Continuation sheets will be numbered on the both sides • Any small errors, in a pocket of larger text, can be scored out with a single line,

dated and initialled. No correction fluid will be used. • All entries will be made sequentially without unnecessary gaps. Where a gap is

unavoidable e.g. when a temporary file is being used, the gap should be ruled through to avoid recording data out of order.

• Blank spaces on continuation sheets will be scored through.

Where records are in paper or electronic format:- • No ditto marks to be used. • Statements must only be written from a clinical or professional perspective. When

writing statements of a personal nature the clinician should always bear in mind that they would be held to account to justify these judgements

• All entries will be made contemporaneously (i.e. during, or at the end, of clinical contact)

http://nww.glospct.nhs.uk/C7/C13/RATIFIED%20POLICIES/Document%20Library/Clinical%20Documentation%20Requirements%2028%202%202011.pdf

http://nww.glospct.nhs.uk/C7/C13/RATIFIED%20POLICIES/Document%20Library/Clinical%20Documentation%20Requirements%2028%202%202011.pdf

http://nww.glospct.nhs.uk/C7/C13/RATIFIED%20POLICIES/Document%20Library/Signature%20List%20master%202%202011.pdf


In exceptional circumstances if it is not possible to complete all the documentation immediately the information must be recorded within 24 hours after the events to which they relate. The entry should be dated and timed at point of entry, ensuring that the date and time the record refers to is clearly indicated, and that the record entry has been delayed

Information which is recorded must be kept in chronological order • Abbreviations must first be written in full with the abbreviation identified in brackets

unless they are on an agreed abbreviation list (See Policy ‘Use of Abbreviations within a Clinical Record’). This list must have the approval of the Heads of Professional/Care services and acknowledged through the clinical policy group. All staff have a responsibility for this issue when writing clinical records. All medication/prescription charts and records must comply with the most recent Gloucestershire NHS Policy for Ordering, Prescribing and Administering medicines (POPAM)

Where records are in electronic format:- Records cannot be deleted from the GCSNHST database:- • A single entry within a health care record may be marked in error in exceptional

circumstances, for example where an entry has been made in the incorrect record or incorrect information has been recorded about a patient. If the staff member has any difficulty with marking in error they should contact the Clincial systems service desk.

• Where a health care record has been duplicated in error, the Admin Lead/Team Leader with designated responsibility for the electronic system must be advised. The Admin Lead/Team Leader will check the details and ensure that all details are electronically transferred to the correct MRN. The clinical systems team must be notified so that the clinical records merge process can be carried out. Once the merge has been confirmed the Admin Lead / Team Leader will check patient record and accept the merge

Social Care records • Information must be entered into the service user’s record on the GCC database.

All additional electronic and paper based information relevant to casework must be added to the database so that the record is complete.

• All information must be recorded in a timely manner as soon as possible after the event and no later than 3 working days after the event. If critical or important information is unable to be immediately recorded, the staff member responsible for recording the information should relay it to another member of ASC staff so that it can be recorded without delay.

• Information must be recorded in chronological order. Information entered after the event must clearly record the date of the event.

• All entries must be written in full and if abbreviations are used, words must first be written in full with the abbreviation clearly identified in brackets.

• Information must be recorded from a professional perspective. Fact and opinion must be clearly distinguished.

• Information provided by a third party must be easily identifiable. • Records cannot be deleted from the GCC database except as detailed below.

Amendments must be documented on the database record and clearly referenced to the original incorrect record.

• A single entry within a social care record may be deleted in exceptional circumstances, for example where an entry has been made in the incorrect record. An email deletion request must be made to the Admin Lead / Team Leader who will confirm that deletion is in order and will have no adverse effect. The Admin Lead / Team Leader will delete the entry and retain the email deletion request as an audit trail.


• Where a social care record has been duplicated in error, the Admin Lead/Team Leader must be advised. The Admin Lead/Team Leader will check the details and ensure that all details are electronically transferred to the correct PRN. The Admin Lead / Team Leader will check with Care Services Finance (CSF) to ensure that the duplicate PRN is not linked to Fostering & Payments system. Once confirmed by CSF, the Admin Lead / Team Leader will then make a written request to ICT to delete the duplicate record.

5.6 Clinical and Social Care Information:- Content. Health Records It is accepted that clinical information may be completed by a variety of members of

the multi-disciplinary team, and that this information may at times be held in more than one place. All clinical information, wherever located must be completed in a clear, concise and contemporaneous format, and include; • A written diagnosis and reason for admission or referral. • An initial patient or user history that includes the history of the presenting

condition, medication details, past medical history and social history. • A report of the initial physical examination performed by a clinician. • Details of referral will be recorded specifying date received • Subjective information defining problems or needs from patient/client • Base line assessment of needs • Long and/or short term goals specified in measurable terms (SMART) where

applicable. • A treatment plan/ plan of care as agreed between the professional and the service

user will be recorded and reviewed at agreed intervals. Due consideration will be given to the sharing of information in accordance with Professional and Local Guidelines of Confidentiality and Consent

• Progress notes, observations and consultation reports. • Information relating to all untoward and unexpected events, and the actions taken

to manage them. • Documentation that mental capacity has been considered and where appropriate

a mental capacity assessment has been completed. In addition: • A record should be entered to include details of non-attendance • The next of kin is to be recorded on the social history sheet, or equivalent. It is

also important to ascertain if this person is also the first point of contact. If not then the first contact details should be clearly documented.

• The hospital / service will contact the named contacts only and the expectation is that these contacts will inform other family / friends as appropriate. Any care undertaken is in line with agreed service guidelines and exceptions must be documented

• Where consent is obtained in accordance with organisational policy, this should be documented

• Inpatient discharge will comply with the organisations Discharge Policy • A copy of any discharge summary, generated by the discharging service, will be

retained in the paper Health Record or in the Patient journal where an electronic record is used.

• Any information which the professional does not wish to be discussed with the service user /client or relative because the disclosure is likely to cause serious harm to the physical or mental health of the patient (Data Protection Act 1998), will be either

a) placed in a separate part of the Health Record designated for confidential documentation. Services who do not keep a central health record will need to describe where this information is stored as part of local processes


b) marked as private where an electronic record is used. • Any information, which the service user /client does not wish to be discussed with

a relative, will a) be placed in a separate part of the paper Health Record designated for

confidential documentation b) a reminder will be placed on the patient record to not share information with

relative where an electronic record is used • Records about patient’s complaints will be held separately from their Health

Record, in accordance with the most recent Gloucestershire Care Services NHS Trust Complaints Policy subject to the need to record any information, which is strictly relevant to their health in the patient’s Health Records

Social Care records Social care information may be documented by any member of the multi-disciplinary

team involved in social care casework with the service user, their family or carers. Records must be accurate, clear, concise, fit for purpose and based on facts verified with the service user and / or others. Records must be written in a manner which respects the dignity and confidentiality of the service user. The service user has rights of access to the information which will only be withheld for reasons permitted by legislation. For example: • Where disclosure is likely to result in serious harm to the service user’s physical or

mental health or condition or that of another individual, including a staff member. • Where disclosure would identify a third party, other than professionals who have

provided information in a professional capacity, who has not consented to being identified.

• Where disclosure would be likely to prejudice the prevention or detection of crime, or the apprehension or prosecution of offenders.

Requests for access to information held within adult social care records are processed through GCC Information Management Services who are responsible for ensuring that information is released in accordance with requirements.

Service user complaints are not held within adult social care records but are instead maintained within the GCC complaints system.

Records must confirm that processes are appropriate and proportionate to the needs and circumstances of the service user / carer and will include: • Referral information. • An assessment, including joint/combined assessments, of service user and

where applicable carer needs against national eligibility criteria. • Evidence that the service user / carer has been provided with a written copy of

the assessment and the eligibility determination, including the reasons why any/all needs are ineligible.

• Evidence of refusal of an assessment where applicable. • Signed consents as appropriate, particularly to obtaining / releasing personal

information. • Where there is any doubt about the service user’s capacity to provide consent,

an assessment of capacity. • Best interest decisions must be clearly recorded and records must confirm that

there has been the least possible restriction on the individual’s rights and freedom of action and that proposed deprivation of liberties are authorised.

• Evidence that potential risks, particularly to safety and welfare, have been explored in appropriate depth. The record must include actions taken to mitigate / manage risk. All safeguarding concerns must be fully documented.

• Documentation of incidents and concerns and the actions taken to manage them.


• Evidence that the service user has been supported to be as fully involved as possible in all decision making. Where relevant, the record should confirm the involvement of a specialist assessor / planner; where communication or other support has been provided; and the involvement of independent advocates where the service user has substantial difficulty in being involved in the process and has no other appropriate person to support them.

• Evidence that the service user / carer has been provided with information and advice where appropriate.

• Evidence that the option of direct payments has, where the service user / carer is eligible, been routinely offered throughout planning and review processes.

• A plan as agreed with the service user / carer which clearly defines assessed needs, how needs will be met, how meeting needs will promote wellbeing and achieve service user/carer outcomes, how the personal budget is made up and includes a review date.

• Evidence that the carer/service user has been provided with a copy of the agreed plan together with personalised information about what can be done to reduce needs and to prevent / delay the development of other needs.

• Monitoring and review information. • The ongoing record of all contact with / for / about / relating to the service

user/carer, including any relevant staff observations. • Documentation of decision making processes, including decisions reached in

supervision. Important decisions and conclusions must be open to scrutiny and review and must show who was consulted, who made the decision and the reasons that the decision was reached.

• Evidence of use of interpreters where applicable. The record must state whether the interpreter was a (named) staff member, family member/friend or other person.

• A recent photograph of the service user if quick recognition is essential. • Appointments missed or cancelled for any reason. • Referrals to other services. • Reason for case closure and confirmation that where appropriate (for example

death of a service user) other GCC services have been advised. • Transfer information where applicable.

All paper based records and correspondence related to casework must be scanned into the service user’s / carer’s record on the GCC database.

Standardised forms / documentation approved by a manager for use in their service area must be used. All relevant fields within standardised electronic documentation or on paper forms must be completed. Fields relating to areas not relevant to the service user’s / carer’s situation, for example during a limited or proportionate assessment, may be left blank.

The responsible staff member must ensure that all casework records are complete and that all relevant parties, including those within other areas of GCC are advised, when a record is closed or transferred.

5.7 Information Sharing 5.7.1 It should be evident within the clinical / social care record that the service user is

aware that information contained within their record may be shared. If the service user has refused to consent to the sharing of information, the record should evidence that the risks of not doing so have been explained to them by staff. All GCCASC service users should be provided with the Your Information: Implementing the National Social Care Record Guarantee leaflet.

5.7.2 In exceptional circumstances and with appropriate justification information may be shared without the consent of the service user. This is likely to be when essential to


the best interests of the patient / service user, or to safeguard the wellbeing of others, and should be documented accordingly. Where staff are unsure then advice of the line manager should be sought in the first instance.

5.7.3 Information contained within GCCASC social care records must be used in accordance with the requirements of the Data Protection Act 1998 at all times and disclosed to others only with the individual’s consent or when GCC has a legal duty or power to disclose. For guidance about information sharing, please refer to the Department for Education’s general Information Sharing Guidance for Practitioners and Managers and specifically the guidance on How to Identify which Rules apply when Sharing Information.

5.8 Electronic Media 5.8.1 The NHS Code of Practice for record keeping and various GCC policies apply to

electronic media in the same way as any other media, and all the best practice principles within this policy therefore apply.

Text Messaging - both outgoing from the NHS / GCCASC and incoming responses from the service user or client • Only mobile phones provided by the relevant organisation to a named individual

must be used. • Professional judgement must be used when responding to a text message from a

service user, client or carer based on the information received. It must be regarded as professional contact.

• No service user/client or carer identifiable details must be transmitted by the practitioner.

• All text messages both outgoing and incoming must be recorded in the GCSNHST clinical or GCC database record including; o The message (as accurately as possible to reflect the content of the

message) o The telephone number o The date and time

• All messages should be deleted from the handset after documentation to maintain confidentiality.

FAX and e mail information GCSNHST

• All faxed information and e-mail information (printed from computer) relating to an individual patient must be kept as part of the clinical record

GCCASC • All faxed information relevant to casework must be scanned into the GCC

database record. • Service user/carer information should only be transmitted by fax if/when it is

possible to verify that the information has been sent to the correct recipient. • The content of emails related to casework must be included in the GCC database

record. Where appropriate, emails should be edited and prefaced within the database record so that the relevance of the emails to casework is clear and the record remains as concise as possible.

• Information should only be emailed outside the GCC network using secure email (either GCSX or Egress Switch)

5.9 Records Management. Please follow the appropriate GCSNHST or GCC Records Management Policy.

5.10 Confidentiality Records and record keeping must adhere to the Professional Code of Confidentiality (GCSNHST), Gloucestershire Information Sharing Policy (GCSNHST), Staff Code of


Conduct (GCCASC), Data Protection Policy (GCCASC) and Caldicott Principles (both organisations).

5.11 Safeguarding ADULT

As part of their role all health and social care professionals must be aware of the impact of both the Mental Capacity Act (2005) and legislation relating to Deprivation of Liberty (2007).The overarching principle of the Mental Capacity Act is that people should be empowered to make their own decisions. Help and support provided to facilitate this process must be clearly documented.

Deprivation of Liberty legislation (2007) came into force in April 2009. This provides a framework for approving the deprivation of liberty for people who lack capacity to consent for treatment in their own best interests, and that can only be provided in circumstances that amount to deprivation of their liberty.

Standard documentation is available within both organisations for Capacity Assessment, Best Interest Assessment and for the process of Deprivation of Liberty application and review.

If an adult with care and support needs appears to be experiencing or is at risk of abuse and neglect, as a local authority GCC has a duty to instigate a safeguarding enquiry. Safeguarding procedures must be followed and documented.

CHILDREN GCSHNST healthcare professionals working with children must be aware of the impact of the Children’s Act (2004)

GCCASC staff who become aware during the course of their work of suspected or alleged safeguarding concerns about a child or young person must raise the matter with a line manager with a view to making a referral to the Children’s Services Helpdesk. All safeguarding concerns should be documented.

5.12 Audit As well as a key finding of the Francis Report the auditing of records and acting on

the results is a good means of assuring the quality of clinical record keeping within an organisation, will identify any areas where improvement can be made and facilitate sharing of good practice.

Requirements: As GCSNHST and GCCASC move towards the integration of patient/service user records, it is intended the organisations will ultimately undertake a joint programme of audit in accordance with the requirements of the GCSNHST clinical audit team. Interim arrangements are defined below.

GCSNHST • All services will undertake an on-going review of clinical health records. • As a minimum audit will take place annually. Action plans are to be completed within three months of the start of the record keeping audit The action plan will be monitored and reviewed after 6 months through locality boards with an interim progress report as required. • Compliance with audit criteria will be RAG rated using a traffic light system.

Compliance 90% and above will be rated green, 70-89% will be rated amber and compliance rated less than 70% will be rated red. Where compliance is rated 70% or below, a reaudit will be expected within the same financial year.

• The audit lead for clinical record keeping will provide a quarterly report on clinical record keeping.

• It is expected that some elements of the record keeping audit will include peer review – as a minimum all registered and non-registered staff who record within


• a clinical record should have at least 2 sets of their client records peer reviewed annually.

• Audit and peer review should be undertaken by staff who have had the opportunity to either audit with an experienced auditor or who have had the opportunity to access training to ensure a systematic and consistent approach.

GCCASC • Adult Social Care records will be audited annually or more frequently if otherwise

directed by the Head of Adult Social Care. Audit will be undertaken through sampling.

• Managers will have overall responsibility for audits of their area of service including ensuring the completion of corrective action plans within timeframes appropriate to the risks involved.

Content GCSNHST -It is acknowledged that audit criteria will vary dependent on the service being provided. Appendix 1 describes core audit criteria that must be included in all clinical record audits, and also outlines the expected scope of all audits. GCCASC –Audit criteria will vary according to the scope and focus of the audit.

GCSNHST Audit Sample Size Audit sample size will vary dependant on the size of the case load, the number of service or clinic locations and the number of health care professionals in that service. To ensure the sample used for a record keeping audit is adequately significant, representative and unbiased lead clinicians should contact the Trust’s Clinical Audit team who will advise using national guidance from the "Guide to Ensuring Data ‘Quality in Clinical Audits" published by the Healthcare Quality Improvement Partnership".

GCCASC Audit sample size will vary dependent on size of case load, number of service locations and staff involved, and the focus of the audit. Advice about sample size will be sought from the organisational audit team.

5.12.1 Monitoring of Compliance Criteria (objective to be

measured) Monitoring methodology Lead responsible Timescales Reporting

arrangements Basic Record keeping Standards

Audit of health and social care records Of the basic record keeping standards described in Clinical and Social Care Record Keeping Policy for all healthcare professionals and GCCASC ICT staff.

Coordinated by audit lead for GCSNHST and GCCASC

Annual unless compliance is under 70% in which case a re-audit will be prompted or evidence of embedded implementation.

Clinical Governance Committee route (GCSNHST) and Managers (GCCASC).

Audit reflecting deficiencies identified from exception reporting / complaints/comments and previous audit

Audit of health and social care records coordinated by audit lead for GCSNHST and GCCASC

Organisational audit Leads

Annual unless compliance is under 70% in which case a re-audit will be prompted or evidence of embedded implementation.

Clinical Governance Committee route (GCSNHST) and Managers (GCCASC).

Record Keeping incidents All record keeping incidents will be monitored through ’datix’ incident reporting system (GCSNHST) and locally within the management structure of GCCASC. All incidents will be reviewed and actioned locally and themes will be monitored through the respective organisation

Local Managers of GCSNHST and GCCASC

ongoing Clinical Governance Committee route (GCSNHST) and Managers (GCCASC).

GCS only Peer Audit:-Non registered

and registered staff who record within a clinical health

should have at an agreed number of their client records peer reviewed

annually. (The number will reflect the organisation)

Audit of notes to be arranged in preparation for annual staff appraisals.

Audit criteria to be set by organisational lead and be appropriate

across organisations and services

Local managers ongoing Local governance arrangements to be

in place


6. Consultation Wide consultation of the policy for version 1 (GCSNHST - detail within archived version 1). Additional consultation within GCC in relation to this first integrated version.

7. Resources 7.1 No cost implications related to this policy. 8. Training 8.1 All clinical and social care staff have a duty to update their knowledge to ensure their

record keeping adheres to the standards set by both their regulatory bodies and the detail of this policy.

GCSNHST The following learning opportunities are provided to support this;

• Training sessions are provided as requested via the Directorate of Nursing and Quality

8.2 Health Visitors and School Nurses must attend mandatory Child Protection Record Keeping Training and obtain a level of competence. Additionally, all new members of the Health Visiting and School Nursing teams must attend this training on induction. If training courses are not immediately available, their allocated Specialist Nurse for Safeguarding Children will give individual tuition. Training updates will be required every two years.

8.3 Health Visitors and School Nurses must ensure that their Support Staff attend the required training and that their A&C Staff are fully conversant with this Policy and work accordingly.

8.4 Training or support related to completion of audit can be access through both the Clinical Audit team and Clinical Quality and Development team at Edward Jenner Court.

8.5 GCCASC Staff must be familiar with the requirements of this policy and the GCC Record Keeping policy and attend case recording training as required.

9 Implementation 9.1 The policy will be communicated to staff via line managers following the approved

processes of each organisation.

9.2 The policy will be made available on the relevant organisation’s intranet and it will also be highlighted in team meetings.

9.3 GCSNHST Information on who to contact for access to the policy from outside the organisation is available on the internet

GCCASC • Policy can be accessed by the public on the Gloucestershire County Council

website. • Partner agencies and other external personnel authorised to carry out social care

functions on behalf of GCC will be made aware of the requirements of this and associated control documents by the commissioners of their services,

10 Equality Impact 10.1 This policy has been subjected to a Quality and Equality Impact Review. This

concluded that this policy will not create any adverse effect or discrimination on any individual or particular group.


11 Quality Impact 11.1 This policy has been subjected to a Quality and Equality Impact review. This

concluded that the policy will not negatively impact upon the quality of health and social care services provided by the Trust.

12 Review 12.1 This policy will be reviewed 3 years from date of issue, or sooner if service need or

change in clinical / social care practice dictates.

13 References, Bibliography and Acknowledgements References, Further Reading and Acknowledgements Audit Commission (1995), Setting the Record Straight/Study of Hospitals Medical

Records, HMSO Publications 1995 Audit Commission (1999), Setting the Record Straight: A Review of Progress in Health Records Services, ISBN: 1862401888 Chartered Society of Physiotherapy (2000) General Principles of Record Keeping and Access to Health Records

DH (2006) Records Management; NHS Code of Practice Mid Staffordshire NHS Foundation Trust Public Enquiry Final Report (2013) http://www.midstaffspublicinquiry.com/report HSC 1999/053, For the Record: Managing Records in NHS Trusts and Health Authorities, HSC 1998/153, Using Electronic Patient Records in Hospitals: Legal Requirements and Good Practice,

NHSE (1999), The Protection and use of Patient Information – guidance from the Department of Health, Department of Health

Nursing & Midwifery Council (2009), Guidelines for Records and Record Keeping, London NMC July 2009 RCN (2006) Use of text messaging services guide for nurses working with children and young people

The Data Protection Act 1998 The Health Professions Order (2001) The Medical Defence Union (2001), ‘Can I see the records’, Clinical Notes-

disclosure and patient access update of 1996 version


Appendix 1 Annual Clinical Record Keeping Audit The minimum requirement for each service is an annual audit of clinical records. The number of records reviewed will depend on the size of the service (see section 5.12 of the Clinical and Social Care Record Keeping Policy for details). Audit Objectives: • To assess effectiveness of, and compliance with the clinical record keeping policy. • To assess compliance with Quality Standards such as CQC, CNST, NHSLA and

CQUINS. In services with electronic records it is acknowledged that some of the parts of the audit described below will not be applicable. Each audit of health records must include: • Patient NHS number • Patient’s full address & postcode • Patient MRN (hospital number) • Ethnic group • Patient name in full • GP name • Preferred name • GP address or telephone number • Date of birth • Details of Allergies / Reactions Where appropriate to the service undertaking the audit, the audit must also include: • Contact telephone number including full STD

code • Name & contact details of person to contact

in an emergency • Gender • Religion • Next of kin / Person with parental

responsibility • Person’s first language

• Person’s key worker or named professional • Person’s occupation/ employment status/school

Each set of audited records must review the following components: • Made contemporaneously or within 24 hours

after the events to which they relate (or policy followed for non contemporaneous entry)

• Statements within the record are written from a clinical or professional perspective

• Abbreviations used in accordance with policy?

• Identification of Mental Capacity and where concerns are raised evidence of a mental capacity assessment.

• Written/typed in black or permanent ink • Subjective information defining problems or needs from patient/client documented

• All entries on paper records must be signed with a identifiable signature / initials

• Errors corrected in line with policy

• Each entry must be dated • Baseline assessment of needs recorded • Each entry must be timed • Long and/or short term goals specified in

measurable terms as applicable • Continuation sheets within paper records are

to be numbered on both sides • Information given to patient recorded

• Evidence informed consent as per Consent Policy

• Information given to relatives / carers of the patient recorded

• Treatment plans / plans of care appropriate to needs of patient in place

• Treatment plan / plan of care recorded and reviewed

• Transfer of care / discharge arrangements • Clear record of management of significant events

If services require help with the audit process then contact the Clinical Audit team located within the respective organisation.

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