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Our expectations for your record keeping

On this page, we run through our broad expectations for your record keeping

This covers what you should record, in what format and when. It also covers how records should be stored.

Record keeping and the standards

The requirement to keep records is set out in our professional standards:

Standards of conduct, performance and ethics

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

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

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

Standards of proficiency

Maintain records appropriately (9)

Keep full, clear and accurate records in accordance with applicable legislation, protocols and guidelines (9.1)

Manage records and all other information in accordance with applicable legislation, protocols and guidelines (9.2)

Use digital record keeping tools, where required (9.3)

The above standards outline in broad terms what we expect of your record keeping. However, the way in which you demonstrate you meet these standards will depend on your profession, job role, local policies, and guidance issued by professional membership and other bodies.

You must make informed and reasonable decisions about your records, which are in accordance with the law and our standards. If asked, you must also be prepared to explain the record keeping decisions you have made.

Establishing what records to keep

When thinking about what records to keep, ask yourself the following questions:

  1. If employed, does my place of work have record keeping / information governance policies that I need to follow?
  2. Does my professional body issue guidance on record keeping, specific to my profession?
  3. Is recording a particular activity required by law and, if so, in what form?
  4. Who is the record intended for, and how might that affect the format or style of the record?

You should use your professional judgement when deciding which records you create and keep. The style and structure of the records you keep will depend on your profession and your scope of practice.

Your manager or supervisor should be able to advise you on what is required. Their advice will be based on circumstances and resources and any procedures adopted locally for record keeping.

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.

We know that prompt record keeping can be challenging, especially for our registrants working in busy front-line services. Often you might be facing time constraints or targets, meaning you struggle to find time to keep records promptly.

We always recommend, as a starting point, to talk to your line manager or supervisor if you have concerns.

If you are still worried after that, you should escalate the issue by speaking to someone more senior or raising the issue in a more formal way.

If you are a member, your union can give you more information and advice. The Advisory, Conciliation and Arbitration Service (ACAS) is another place you can turn to.

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.

Advice is also available from the Information Commissioner’s Office (ICO), the UK authority on information rights and data protection. 

Tudalen wedi'i diweddaru ymlaen: 24/03/2021