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Record keeping

Full, clear and accurate record keeping is vital to the delivery of safe and effective healthcare

Once you are registered with us, you have a professional responsibility to keep full, clear and accurate records for everyone you care for, treat or provide other services to. 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.

What records you need to keep, in what format and for how long, varies depending on the setting you are working in and the subject matter of those records.

Page updated on: 24/03/2021