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Record keeping under pressure

This information aims to support registrants in understanding how to apply the following Standards of conduct, performance and ethics during the COVID-19 pandemic.

10.1 You must keep full, clear, and accurate records for everyone you care for, treat, or provide other services to.

10.2 You must complete all records promptly and as soon as possible after providing care, treatment or other services.

10.3 You must keep records secure by protecting them from loss, damage or inappropriate access.

Meeting HCPC standards in a challenging environment

It is important you keep records, so that information can be shared with colleagues involved in providing care and treatment, decisions on treatment can be made and legal obligations can be met. 

However, we recognise that during the COVID-19 pandemic this may become more difficult; when there is more pressure on time and resources.  You may also be working in a challenging environment which might mean you are unfamiliar with record keeping policies and processes.

Although our standards apply at all times, they are not prescriptive and allow for flexibility.  This enables registrants to respond to changing operational demands and working patterns,especially so during the COVID-19 pandemic. 

This means a departure from normal record keeping procedures might be expected, but registrants need to ensure this does not have any adverse impact on service delivery or the safety and wellbeing of service users.

Keeping records

We expect you to exercise your professional judgement when deciding what records you create and keep in order to continue to meet our standards.  You have a professional responsibility to keep full, clear and accurate records. This is to:

  • safeguard continuity of care by providing information to colleagues involved in care and treatment;
  • ensure service users receive appropriate treatment that is in their best interests;
  • meet legal requirements or respond to Freedom of Information or Subject Access Requests; and
  • evidence your decision-making processes if later queried or investigated.

The style and structure of the records you keep will depend on your profession and may need to be adapted in the light of COVID-19. 

Your manager or supervisor should be able to advise on what is required.  Their advice will be based on circumstances and resources and any procedures adopted locally for record keeping during the COVID-19 pandemic.  This will be especially helpful if you are in a new or unfamiliar role.

Professional bodies have published advice and guidance to help with profession or role-specific issues. You can see a list for of these on our professional bodies page.

Completing records promptly

Records need to be completed promptly to ensure continuity of care. You should make sure that the records can be shared with colleagues as soon as possible after care and treatment. This may take a little more time than usualbecause of the pressures of COVID-19.   

Our blog on Commonly asked record keeping questions, answered may help you in deciding on your approach.  It acknowledges the time pressures registrants may face at the best of times and how these may affect their record keeping. 

These time pressures will be magnified by COVID-19 and we recommend that if you have concerns about your ability to keep accurate records, you should raise them first with your line manager or supervisor. 

If necessary, you can raise them more formally with your employer or with your trade union/professional body. 

Ultimately, record keeping remains an important part of your practice and should be maintained during COVID-19. You should ensure you keep within the requirements for accuracy, timeliness and confidentiality.

Justifying decision making

Your records should provide evidence of the decisions that have been made and the care and interventions provided.  They should help to ensure that service users receive appropriate treatment that is in their best interests. 

Your records should also help you to evidence your decision-making processes if later queried or investigated.  You should ensure that you record and explain any changes to practice because of COVID-19.

Keeping records secure

It is important that records are kept safe from being lost, damaged or accessed inappropriately.  Whatever system is used for record keeping where you are, it must protect service users’ confidentiality.

You should also keep in mind the legal requirements for data protection and Freedom of Information and Subject Access Requests. These still apply to records kept during COVID-19. For further advice, we have published guidance on data protection in exceptional times.

Advice is also available from the Information Commissioner’s Office (ICO), the UK authority on information rights and data protection.  The ICO have published a statement about how they will regulate during the COVID-19 pandemic. They have also issued a statement on data protection and coronavirus and created a data protection and coronavirus information hub.

Related links

Our joint statement with other health and care regulators explains how we will approach regulation and fitness to practice during the COVID-19 pandemic.

We have our own UK-wide advice and resources for record keeping.

Please note that the Scottish Government revised their Records Management: NHS Code of Practice in 2012.

Tudalen wedi'i diweddaru ymlaen: 22/04/2020