Example standards

An example statement

The secure storage and safe disposal of care records is a statutory requirement. This example standard statement is quite broad, incorporating the legal and local requirements, irrespective of your location or area and level of practice.
 
6.2  Your care records must always be kept securely and disposed of according to legal requirements and local policy
 
The statement is then broken down into explicit criteria against which you need to evaluate your practice or service.
 
These are a few examples:
 
6.2.1  Your storage equipment, systems or facilities keep your records safe from theft, loss, false access or damage
 
This is partly a structure-related criterion. You will need to see what equipment and facilities you have in your department or office, whether it is a paper or electronic system. Does it meet the requirements of the criterion? It is also a process-related criterion. Do you and your colleagues use these systems and facilities properly? If the answer to both these questions is ‘yes’ you would score 2. If you have the facilities but do not use them, you would score 1. If you have no facilities or processes to keep your records securely, you are not meeting this criterion and you would score 0. This indicates that you need to make improvements.
 
6.2.8  Your workplace diaries are kept for a minimum of two years after the end of the year to which the diary relates
 
You will need to check what happens to all the diaries kept within your workplace that relate to intervention with your service users, whether they be the departmental diary or practitioner diaries, paper or electronic.

Qualitative criteria

Some criteria are less objective. For example:
 
6.4.2  Your care records are legible
 
6.4.3  Your care records are concise
 
In such a circumstance it may be better for someone else to audit your records. You are used to your own style of record keeping. It may be that someone else looking at your records will have difficulty understanding your handwriting or the terminology you use. Please note, when auditing the content of care records, it must be appropriate for the person who does the audit to have access to the care records.
 
For the more behaviour-based criteria, you will need to audit your practice through reflection and discussion, perhaps with your colleagues or as part of supervision. An example of this might be:
 
2.2.2 You treat your service users with respect at all times
 
Your colleagues or your supervisor will be able to give you feedback on your practice, and on the behaviours and attitudes that they see you display in the workplace.  You may have to come to an agreement as to what it means to ‘treat your service users with respect at all times’. You may be able to involve your service users to provide you with feedback, perhaps by having a feedback form with questions relating to their experience and their perception of the way they were treated. For this example, if you consistently treat your service users with respect at all times, you would score 2 on the audit sheet. If your attitude was less constant, you would score 1. In the unlikely event that your attitude was considered to be consistently rude, you would score 0.