Records created by healthcare workers are considered health records under UK law. Health records must be factual, consistent, accurate, dated, timed, signed, and avoid jargon. Poor record keeping can lead to issues like mistakes in care, complaints, disciplinary action, and even criminal proceedings. The main barrier to good record keeping is a lack of time. Records made by non-registered staff must be regularly countersigned by their supervisor.

1. Record Keeping
By Sharon Leverton

2. Definition
A health record is defined in section 68(2) Data
Protection Act 1998 as:-
• Information relating to the physical or mental
health or condition of an identifiable
individual.
• Records being made by or on behalf of a
health professional in connection with the
care of an individual.

3. Quiz!
Q1. Is your work diary classed as a health care
record?
A. YES
Q2. As an Health care worker are the records
that you create deemed as public records?
A. YES

4. True Or False
Q3. Everyone working for or with the NHS who
records, handles, stores or otherwise comes across
information has a personal common law duty of
confidence.
A. TRUE
Q4. The Data Protection Act 1998 now places
statutory restrictions on the use of personal
information, including health information.
A. TRUE

5. Delegation &
Countersigning Standards
• Records created by non registered staff must be
countersigned at the end of each episode of care
or at least 4 monthly for Level 1 & level 2 patients
• For complex patients the caseload holder retains
the responsibility for all delegated tasks
• In these cases the caseload holder should make
the decision on the frequency of countersigning

6. What Are The Benefits
Of Good Record Keeping?
• Easier continuity of care
• Documentary evidence of services delivered
• Communication and sharing of information
between members of the multi-professional
healthcare team
• Identify risks and enabling early detection of
complications
• Supporting clinical audit, research, allocation of
resources & performance planning
• helping to address complaints or legal processes

7. What Makes A
Good Health Care Record?
• Factual, Consistent, Accurate
• Consecutive & Chronological
• Written up as soon as possible
• Legible Handwriting
• Dated, Timed & Signed
• Free of jargon
• Non judgemental
• Involve patients
• Evidence of care planned, care delivered and
information shared

8. Quotes Taken From
Healthcare Records
• “By the time he was admitted, his rapid heart
had stopped and he was feeling much better”.
• “Her husband seems surprisingly sensible”.
• “Mr X thinks more of his dog than his wife”
• “Between you and me, we ought to be able to
get this lady pregnant”.
• “The lab test indicated abnormal lover
function”.

9. How Can You
Avoid Similar Mistakes?
• Read back your own records and
those of others
• Audit records in line with policies
and procedures

10. What Is The Main Barrier To
Maintaining Accurate Records?
• No paper
• Not being able to use a computer
• Time
• Not knowing what to write
• Not being familiar with standardised medical
abbreviations

11. What Are The
Consequences of poor
record keeping?
• Poor patient care
• Lack of continuity of care
• Mistakes
• Complaints
• Scrutiny of documentation
• Disciplinary procedures
• Criminal proceedings
• Death

12. When Things
Go Wrong
• Clinical supervision
• Notes review
• Incident reporting
• Governing body support and advice

13. http://www.nmc-uk.org/Hearings/Hearings-
and-outcomes/
http://www.hpc-uk.org/complaints/hearings/

14. http://www.justice.gov.uk/downloa
ds/burials-and-coroners/guide-
charter-coroner.pdf

15. Remember!
“IF IT IS NOT WRITTEN
DOWN, IT WAS NOT DONE”

16. Please complete and hand in all your
feedback forms.
Thank you for your time!
Sharon Leverton