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Records ManagementCQC Inspection

Alan Ferguson:

Records Manager & Quality Facilitator

Records Management CQC Briefing Dec 2015 V1

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Records ManagementRecords Management covers all aspects of how we deal with information, both clinical and corporate, on a day to day basis.

Key requirements that apply to records management include:

Sources: *Records Management NHS Code of Practice. **Information Governance Toolkit – Corporate Assurance 601/602

Care Quality Commission (Regulation 17 – Good Governance)

NHS Litigation Authority Risk Management Standards

Information Governance Toolkit

Professional Codes of Practice

Litigation Authority

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The Care Quality Commission

Purpose:

They make sure health and social care services provide people with safe, effective, compassionate, high-quality care and they encourage care services to improve.

Role:• Register care providers.• Monitor, inspect and rate services.• Take action to protect people who use services.• Speak with an independent voice, publishing regional and

national views of the major quality issues in health and social care.

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Regulation 17 – Good Governance

Records related extracts:

17 (c) maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided

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17 (d) maintain securely such other records as are necessary to be kept in relation to:

(i) persons employed in the carrying on of the regulated activity, and

(ii) the management of the regulated activity

Regulation 17 – Good Governance

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Patient / Client recordsThere are a number of factors that contribute to effective Record Keeping, these include:

Handwriting should be legible Records should be readable when photocopied or scanned All entries to a record should be accurately dated, timed and

signed, with the full name and designation printed alongside the first entry where this is a written record, and attributed to a named person in an identifiable role for electronic records

Your records should be accurate and recorded in such a way that the meaning is clear

Records should be factual and not include unnecessary abbreviations, jargon, meaningless phrases or irrelevant speculation

Continued …

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Patient / Client records• You should record details of any assessments and reviews

undertaken and provide clear evidence of the arrangements you have made for future and ongoing care. This should include information given about care and treatment

• Records should identify any risks or problems that have arisen and show action taken to deal with them

• Where appropriate, the person in your care or their carer, should be involved in the record keeping process

• The language that you use should be easily understood by the people in your care

• You must not alter or destroy any records without being authorised to do so

Remember – “If it is not recorded it didn’t happen!”

Source: NMC Record Keeping Guidelines – July 2009

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Feedback from Self Assessment Visits

• Ensure that all patient health records are reflective of patients' assessed needs and record the involvement of the patient, carers and family in the care and treatment of the patient

• Security of records: ensure that all filing cabinets/cupboards are able to be locked

• Ensure records are transported in a secure and safe manner

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Feedback from Self Assessment Visits

• Ensure all archiving of records is up to date. Check areas to ensure there are no “legacy records” from previous services/teams in your areas

• Ensure Policies are up to date and current documentation we are using has the SCHT Trust logo and not previous PCT logos

• Ensure that computers are locked when unmanned so that no unauthorised person can access it.

Tip: To quickly lock your computer use the shortcut keys “ + L”

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CQC Information for Staff

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Useful References

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