Our standards say that you should keep and maintain records for all your service users that are:
Below, we have listed the common questions that registrants have raised with us about record keeping.
Our responses to these questions should help you better understand our approach to record keeping, and our expectations of you in this area:
There isn’t one right way – it will depend on your practice and your profession. Our standards say that you should keep records for all your service users that are: - full, clear and accurate;
- completed as soon as possible; and
- kept safe from being lost, damaged or accessed inappropriately. Ultimately, no matter what system you use, it must protect service users’ confidentiality – whether that’s password protection for electronic records, or a locked filing cabinet for paper ones. You should also be confident your record keeping practice meets legal requirements. As record-keeping practice differs depending on where you work and your profession – you might also want to speak to your employer and your professional body / trade union. They have lots of experience in this area and can give you practical tools and tips to make sure you’re getting it right. If, after speaking to your employer and professional body / trade union, you still have questions about the types of records you should be keeping, you might want to get advice from a lawyer with knowledge in the area.
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. Our Standards of conduct, performance and ethics require you to ‘complete all records promptly and as soon as possible after providing care, treatment or other services’ (10.2). How soon after will therefore depend on best practice in your profession, any policies set by your employer and your professional judgement. You should consult local guidance and policies on record keeping at your place or work or issued by your professional body if a member. If you are uncertain, you should raise this with your line manager or supervisor.
Other factors in my workplace are affecting the time I have available for record-keeping. What should I do?
We understand the pressures on registrants, which can mean finding time for record keeping is challenging. If you have any concerns about factors in your workplace affecting your ability to meet the standards, we advise first talking to your employer about your concerns. If you are still worried after that, 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.
What do I need to do to keep records confidential when they are stored electronically?More and more healthcare services are switching to storing patient records electronically. This is fine, as long as the record-keeping system you’re using allows you to meet our standards and follow the law. Our standards say you must keep service users’ information confidential and secure. The General Data Protection Regulations (GDPR), supported by the Data Protection Act 2018, apply across the UK and govern how personal information, including service user records, should be handled. If you’re looking for more information on data protection, the Information Commissioner’s Office has useful guidance on deleting personal data and what to do in the event of a data breach. Our confidentiality guidance also includes more detail on electronic records.