CQC: safe record keeping - guidance

Safe record keeping is of paramount importance to ensure the high quality care of our patients.

We are focusing on ensuring that documentation is of the required standard, as set out by the Nursing and Midwifery Council (NMC) and the General Medical Council (GMC).

In 2019 and 2020, the Care Quality Commission (CQC) highlighted some areas for improvement at PAHT:

The trust has still not taken enough action to ensure that records of care and treatment are clear, up to date and easily accessible CQC

The services must ensure that staff keep detailed records of patients’ care and treatment CQC

We are in a period of transition, moving from paper-based recording of care and treatment to electronic systems. We are currently exploring moving to full electronic patient records. The trust wide documentation action plan is in place to safely manage how we accurately record all care and treatment of patients in a timely manner.

Do

Use timed entries at the point of care or as soon after

Do not

Use abbreviations

Keep clear, accurate and legible records – clearly signed and dated

Document any non-compliance, concerns and actions trackable Make offensive, humorous or personal comments

Use ambiguous terms

Document escalation and actions taken – date, time and sign

Document oral communications (phone calls, in person conversations etc) and actions taken Delete or alter the contents of clinical notes in a way that is not

Document informed consent

State objections/plan regarding care or case management

Collect, treat and store all data and research findings appropriately Take all steps to make sure that records are kept securely – locked notes trolleys

For further information, please refer to:

The Nursing and Midwifery Council website: www.nmc.org.uk The General Medical Council website: www.gmc-uk.org