Clinical Record Keeping Policy by liaoqinmei



Version Date          August 2008
Version Number        3
Status                Approved
Next Revision Due
EqIA Number           NUR/07/E18 Reassessed August 2008
Developed By          Bev Harris & Lyn Barwick
Policy Sponsor        Head of Professional Development Adult Services
Approved by           Provider Services Clinical Governance Committee
Date approved         Sept 2008

Revision History
Version      Revision Date          Summary of Changers
1            August 08              Changes made to roles and
                                    responsibilities and monitoring the
                                    implementation of the policy.
                                    Changes made to EIRA Assessment


  1.     Aim                                                3
  2.     Background                                         3
  3.     Clinical Speciality                                3
  4.     Organisational Accountability / Responsibilities   3
  5.     Intended Users                                     4
  6.     Definitions                                        4
  7.     Indications for Use                                4
  8.     Contraindications                                  4
  9.     Equality and Impact Statement                      4
  10.    References                                         5
  11.    Context of Policy                                  5
  12.    Content and Style                                  5
  13.    Patient and Client Involvement                     6
  14.    Legal Aspects of Clinical Records                  7
  14.1   Community Hospital                                 8
  14.2   Community Nursing                                  8
  14.3   Health Visiting & School Nursing                   8
  14.4   Allied Health Professionals                        8
  14.5   Dentistry                                          8
  14.6   Podiatry                                           8
  14.7   Contraception & Sexual Health                      8
  14.8   Learning Disabilities Clinical Teams               8
  14.9   Documentation of Controlled Drugs                  8
  15.    Patient/Client Held Records                        9
  16.    Electronic Clinical Records                        9
  17.    Clinical Audit                                     9
  17.1   Minimum Content of Audit Reports                    9
  17.2   Frequency of Audits                                10
  17.3   Action Plans                                       10
  17.4   Monitoring and Performance Management of Policy    10
  18. Access to Clinical Records                            10
  18.1 Retention of Records                                 11
  18.2 Transportation of Clinical Records                   11
  19. Support and Additional Contacts                       11
  Appendix 1     EIRA Assessment

1.     AIM
It is the aim of this policy to set out the context by which all clinical records
should be completed, and are in line with each of the professional bodies
Clinical Records Standards. The policy supports and should be read in
conjunction with the Trusts “Records Management Policy”.

Record keeping is an integral part of a clinician’s clinical practice and duty of
care, it is a tool which should aid the care process and should not be seen as
separate from this process and is not an optional extra. Whilst records are
generally hand written, the clinical record could also include computer
records, audio tapes, emails, faxes, video tapes, photographs, compact disc’s
and other electronic media. All clinical records regardless of format or type
should protect the welfare of the patient/client by
    High standards of care,
    Continuity,
    Better communication between the inter-professional team involved in
        the provision of care,
    An accurate account of assessment treatment, care planning and
    The ability to identify risks, and detect problems
    Confidentiality

All adult and children’s services where care is provided by a clinician

The Chief Executive has overall responsibility for the management of clinical
records within the Trust.

The Director of Quality & Nursing has been delegated the responsibility of
clinical records management by the Chief Executive.

Head of Service have the responsibility of ensuring that all their staff have
received training in the relevant aspects of clinical record keeping and that
they are compliant with the Clinical Record Keeping Policy.

All health care professionals have a legal duty of care and are responsible for
any records that they create or use in relation to patient/client care, this
responsibility is established and defined by law.

Where a health care professional is aware (or could reasonably be expected
to be aware) that there is an increased possibility / risk of error (caused by
temporary or permanent individual circumstances) in recording, filing or
retrieving patient records, this must be raised with the individual’s manager.

This will then enable a risk assessment (or other appropriate action) to be
carried out, with the aim of identifying required actions to remove or minimise
the risks.
The policy sponsor for this document is the Head of Professional
Development Community services (Adults) and as Chair of the Derbyshire
Community Health Services Clinical Committee is also responsible for
ensuring that the audit of clinical records is undertaken annually

All clinical staff providing care

There is no actual definition of a Clinical Record, therefore this has been
broken down into “Clinical” & “Record”.

Clinical:      Relating to observation and the treatment of patients

Record:        Register set down for remembrance or reference, which is in
               permanent form, and provides evidence of information.

All patients/clients admitted into the Trust for clinical care/treatment



We welcome feedback on this policy /procedure / strategy and the way it
operates. We are interested to know of any possible or actual adverse impact
that this policy / procedure may have on any groups in respect of gender or
martial status, race, disability, sexual orientation, religion or belief, age,
deprivation or other characteristics’.

The person responsible for equality impact assessment for this policy /
procedure / strategy is Bev Harris, Head of Professional Development.

This policy has been screened to determine equality relevance for the
following equality dimensions:

    Age
    Disability
    Gender
    Race
    Religion/Belief
    Sexual Orientation
    Transgender/Transexual

The policy is considered to be particularly equality relevant for the dimensions
of: disability, race and, in some circumstances, age. The equality relevance is
considered to be high. A full impact assessment will be conducted by June
2009. The initial impact assessment screening is included at Appendix 1 of
this policy.

CSP 2005 Core Standards of Physiotherapy Practice
Data Protection Act 1998
DCPCT Access to Health Records Policy
DCPCT Approved List of Abbreviations
DCPCT Audit Timetable
DCPCT Confidentiality Code of Conduct
DCPCT Information Governance Policy
DCPCT Records Management Policy
DCPCT Preservation, Retention & Destruction Policy
DCPCT Transportation of Records Policy
DH 1997 Caldicott Report
DH 2006 Records Management: Code of Practice Parts 1& 2
DH 2004 Standards for Better Health Care
Freedom of Information Act 2000
GMC 2006 Good Medical Practice
HPC 2008 Standards of Conduct, Performance and ethics
Mental Health Care Commission Standards 2004
NMC 2008 The Code: Standards of Conduct, Performance and ethics for
Nurses and Midwives
NMC 2007 Record keeping: A-Z advice Sheet
PCT Information Governance Policy
PCT Confidentiality Policy
PCT Mental Capacity Act Policy

The best clinical record is the product of consultation and discussion between
all members of the inter-professional health care team and the patient/client,
and carers/relatives/advocates. The record must be evaluated and amended
in response to the needs of the patient/client. The record should enable any
member of the health care team to care for the patient/client regardless of
where they are within the care process or care environment. In line with the
Single Assessment process (SAP) the record is required to promote
communication between those individuals involved in the provision of care
and with the patient/client, their carers/relatives/advocates and reduce
unnecessary duplication of assessments

There are several factors that contribute to effective record keeping, all
records should be commenced at the time of the initial contact and be:
    Factual, consistent, accurate and recorded in a way that is clear and

      Recorded as soon as possible after the event, providing current
       information on the intervention, and the condition of the patient/client.
      Legible, concise, and in such a manner that the text cannot be erased
       or deleted without a record of change.
      The record should be sequential and be recorded in such a manner
       that any justifiable alterations or additions are dated, timed and signed
       clearly, all entries should be attributed to a named individual, in an
       identifiable role in such a way that the original entry can still be read.
      Any necessary deletion due to an error should be made with a single
       line striking through the relevant error in such a way that the error
       remains legible. Correction fluid should not be used
      Each entry must be dated timed and signed including errors or
      Entries made by students should be countersigned by their
      Only abbreviations from the PCT approved list should be used, the
       record should use where possible terminology that is understandable
       for both carers patients and professionals. The record should not
       contain meaningless phrases, irrelevant speculation, offensive or
       subjective statements.
      References to third parties unless significant to the patient/clients care
       should not be used.
      The record should be readable when photocopied or scanned.

All records must include two patient identifiers: the patient’s name, and
NHS Number. These should be recorded on each separate page/sheet
within the record. All records where patients are being cared for in a
clinic/hospital/ward environment must also include the name of the
hospital and ward/department

In addition the record should:-
     Be recorded where possible with patient/client, carer/relative/advocate
     Be recorded in terms that the patient/client, carer/relative/advocate can
     Identify risks and or problems, variances from the care plan, that have
       arisen and the interventions made to rectify this
     Provide clear evidence of the care planned as a result of the
       assessment, the decisions made, care delivered, the information
       shared and with whom.

Patients and clients should be equal partners in the assessment and decision
making process of their care and the compilation of the clinical record. Where
patients do not have the mental capacity to be involved in this process then
staff should refer to the Trust Mental Capacity Policy. Staff should also take
into consideration the Data Protection Act 1998: the Access Modification
(Health) Order 1987 and the Access to Health Care Records Act 1990.

Procedures for access must be in accordance with the Freedom of
Information Act 2002.

In some cases registered clinical staff can withhold information if they feel that
in their professional judgement the provision of information may cause serious
harm to the patient/clients physical or mental health or would breech the
confidentiality of another patient/client. Registered clinical staff who make
such decisions must be able to justify the reasons for withholding information
and ensure a record for this has been made.

Some patients and/or their carers / relatives / advocates may have more
difficulty than others in communicating and understanding matters relating to
their medical records. Consequently, staff involved in the policy’s
implementation will need to proactively consider the additional actions that
might be required to ensure that the requirements of all patient groups can be
met as far as is practicably possible when: involving and communicating with
patients and other relevant parties.

Registered clinical staff have both a professional and legal duty of care in line
with clinical governance and patient safety, and must ensure that their records
give a full account of their:
     Assessment
     Care planned and provided
     Relevant information about the condition of the patient/client at any
        given time
     That all reasonable steps have been taken to care for the patient,
     That any actions or omissions on the part of the registered professional
        have not compromised the safety of the patient/client in any way.

Where patients meet the Continuing Care Criteria evidence of the decision
making process must be recorded with in the clinical record.

Registered clinical staff who are working with patients/clients, who are subject
to mental health legislation, must ensure that they have a thorough working
knowledge of the statutory powers as they apply to their particular area of
practice. When making entries into clinical records for these patients/clients
they must comply with guidance given by the Mental Health Act Commission
for England 2004.

Registered clinical staff who are professionally accountable for ensuring that
any duties they delegate to members of the multi-professional team who are
not registered with a professional body are undertaken to a reasonable
standard. For instance if a registrant delegates work which requires a student
or Health Care Assistant to make a record in the patients clinical record they
must ensure they have the necessary knowledge and skills to undertake this
aspect of care. Where the student or Health Care Assistant has not been
assessed as being competent to undertake record keeping then the registrant
must countersign the entry in the clinical record. Registrants remain

professionally accountable for the appropriateness of the delegation and the
actions or omissions of the student or health care assistant.

Registered clinical staff are required to use their professional judgement in
deciding what is relevant to record within the patient/clients record; this
applies particularly to situations where the patient/clients condition is
unchanging. In these circumstances the Trust requires any registrants to
ensure an entry is made in the record at a minimum of:

Entries made in the multidisciplinary patient record must reflect all care
delivered by any member of the multidisciplinary team within a 24 hour period.
Treatment plans must be evaluated and reviewed and recorded as changes
occur but at least once a week as a minimum.

Monthly for each care problem, but this will be dependent on the acuity of the
problem and may be weekly, daily, or more frequent as the patients condition
dictates. For patients whose care is being evaluated and reviewed for
continence problems or B12 therapy then a record should be made six
monthly minimum.

Every face to face contact and significant telephone contact.
Significant information in relation to other services that contribute to the care
of the client should also be required.

14.4 Allied Health Professionals
At each Contact.

14.5 Dentistry
At each Contact.

14.6 Podiatry & Optometrist
At each Contact.

14.7 Contraception & Sexual Health
At each Contact.


   Community staff record every face to face contact and telephone contact.
   In-patient area staff record daily during admission.
   Hand held Health Action Plans in accessible information format are
    developed for each individual who wishes to hold one.
   Supplementary to the Health Action Plans are Health Surveillance
    Records which are filed in nursing notes.

Registered clinical staff must remember that in a court of law the approach
taken is that “if it is not written down it has probably not been done”, and this

will be the approach taken within the Trust: when records are used for the
purposes of clinical audit, and investigations into complaints and incidents.

Please refer to the Trusts Medicine Code.

With the introduction of the Single Assessment Process (SAP) and the
Patient/Parent Held record (PHR), many patients hold their own records and
this should be encouraged where possible. Patients/clients should be
informed of the purpose and importance of the record and their responsibility
for keeping it safe, a record of the discussion and the advice given should
also be made in the clinical record.

Registered clinical staff may need to keep supplementary records to which
access by the patient/ client is limited or withheld, in such cases this should
not extend to keeping a full duplicate of records and should be the exception
rather than the norm. In such circumstances registrants should be able to
justify the keeping of a supplementary record and its existence must be made
clear to all the health care team involved in the care/treatment of the

Within Child & Family services the Trust Child Health Records is the only
clinical record that is maintained by health professionals.     No other
supplementary record should be raised.

Where electronic records are kept there is no requirement to keep duplicate
paper based clinical records. All record keeping using whatever medium
should take account of the need to maintain communication between the
multi-professional health care team providing care/treatment for the
patient/client. Staff should refer to the Trust Information Governance Policy.

The principle of confidentiality is equally important when electronic clinical
records are being used including those sent by fax/email and should comply
with the Trust’s Information Governance policy. Registered clinical staff are
professionally responsible for making sure that whatever system they use is
fully secured and managed in such a way that confidentiality is maintained.

Registered clinical staff are accountable for any entry made with in the
electronic record and must ensure that any entry made is easily identifiable.
Shared passwords are unacceptable and should never be used, please refer
to the IM & T Security Policy

Clinical audit is one component of risk management and the improvement of
clinical standards and applies equally to the process of clinical record
keeping. By auditing the record registrants are able to assess the standard of
record keeping and identify areas of improvement and staff development. The

criteria against which clinical records must be audited are those identified in
the Content and Style section of this policy.

The minimum content of clinical records will be audited using the PCTs
standardised Clinical Records Audit Tool. Results of audit will be reported on
using the Standardised Clinical Audit Reporting Template. The audit tool and
reporting template can be found on the Trusts Intranet.


All registrants are required to participate in undertaking audit of clinical
records according to their Dept/Ward/Teams respective annual clinical audit
plans. Staff should refer to the Trust’s Clinical Audit Committee for
advice/support where appropriate. The percentage of clinical records audited
and frequency should be identified clearly in the respective service/s annual
clinical audit plan, as a minimum clinical records audit should be taken


Action plans will be developed as a result of the Clinical audits and will be
presented to the relevant Governance Committees within the trust. Actions
from this will be cascaded to the appropriate areas for implementation with
progress reported back the Governance Committees on a regular basis.


The use of this policy will be monitored and performance managed by the
Quality & Nursing Directorate Team. All clinical records audit reports and
resulting action will be reported to and monitored by the Children Young
People and Disabilities, and Adults and Older People Clinical Governance
Committees, it will also be monitored via the PCTs Clinical Audit Committee,
and any exception reports reported to the Provider Services Clinical
Governance Committee.

The clinical records audit tool should be reviewed annually to ensure the
necessary data is available to provide a comprehensive report to monitor the
effectiveness and adherence to the clinical records policy.

The Trust supports the principle of shared records in which all of the health
care team involved in the care and treatment of patients/clients makes entries
in a single multi-professional record and in accordance with the shared record

policy. Each member of the health care team’s contribution to the clinical
record should be seen as of equal importance.

Patients /clients records may be used for, teaching or clinical supervision, the
principles of access and confidentiality remain the same and the
patients/clients right to refuse should be respected.

Research governance requires that consent to access and use records for
research purposes is sought from each patient invited to participate or whose
records may be used. Provision for this in the research proposal will be
required as part of the pre-research ethical approval process.

A patients/clients right of access to their health records is governed by the
provision of the Data Protection ACT 1998, Access to Health records Act
1990, the Caldicott principles and must be in accordance with the Freedom of
Information Act 2000, and the Trust Policy for access to Health Records.

The period for which patients/clients clinical record is kept is subject to
legislation and The Records Management: NHS Code of Practice, which is
available on the Trusts Intranet. see Appendix 1

The Trust Recommends that clinical information pertaining to a patient/client
should not be kept in diaries. Where information is recorded in a diary it will be
considered as being part of that patients/clients clinical record, clinical
information can be transferred from the diary into the clinical record, the diary
would then need to be retained for two years and will be required to be
retained in line with the patient/clients clinical record.

For telemedicine or use of recorded patient information/records refer to
section in Retention of Records under telemedicine.

For the transportation of clinical records please refer to the Trusts
Transportation of Records Policy.


The name/s of the people responsible for developing the document and from
whom additional support and advice can be obtained in order to implement
the document are:

      Bev Harris Head of Professional Development Adult Community
      Lyn Barwick Head of Professional Development Community Hospitals
      Jenny Mellor Head of Professional Development Children’s and
       Speciality Services

Based at Toll Bar House 0115 931 6100.


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