Record keeping

6. You have an obligation to keep care records that are fit for purpose and to process them according to legislation

Record keeping is an intrinsic part of the care that you provide. It is not an ‘add-on’ or an optional task. You have a legal obligation to keep care records, whether in paper or electronic form, that are fit for purpose, to facilitate the care, treatment and support of service users.
 
Your records should provide a comprehensive, accurate and justifiable account of all that you plan or provide for service users and, where appropriate, their carers or relatives. You should protect time within your daily routine to fulfil your record keeping requirements. The court’s view is that if it isn’t recorded then it didn’t happen, was not said or was not done. (Lynch 2009, p50)

Your duty of care

Good practice in record keeping protects the welfare of service users and, as such, forms part of your duty of care. You must be aware of and meet all requirements in relation to record keeping, whether in legislation, guidance or policies.
 
In 2005 Brigit Dimond wrote:

Failure…to maintain reasonable standards of record keeping could be evidence of professional misconduct and subject to professional conduct proceedings. Such failure could also lead to disciplinary action by an employer and have very strong influence on any action brought in the civil courts by a claimant who alleges that he/she has suffered harm as a result of inappropriate care or treatment possibly as a consequence of failures to maintain reasonable standards of record keeping. (Dimond 2005, p460)

Confidentiality, security and data sharing

Legislation requires you to store and process care records in particular ways. You need to be aware of the key obligations this puts upon you in relation to confidentiality, security, data sharing or processing and peoples’ access to their care records. Further information is available from the College of Occupational Therapists guidance on Record keeping (COT 2010l).
 
The Data Protection Act 1998 (Great Britain. Parliament 1998b) requires you to tell your service users why their information is required, what will generally be done with the information and who it is likely to be shared with. Except where the law requires disclosure, you must obtain your service users’ consent before you share details from their care records with those who are not part of the direct care team.
 
All security, confidentiality and data sharing principles apply to electronic recording systems as well as paper systems. Mobile phones and personal digital assistants (PDAs) effectively act as mini-computers, and are subject to similar security threats and vulnerabilities, particularly when the internet, or email communication, is involved. Access should be password protected and information/files should be encrypted. Any patient information that is transferred electronically should be encrypted and the keys handled securely.
 
Your employer is responsible for providing secure devices that are usable in real-life situations, also for agreeing and implementing effective and practical policies to cover the use and transfer of service user information, by whatever means. Electronic devices used for recording service user data are covered by stringent security requirements. You should be sure that you do not contravene these when using any kind of portable electronic equipment, including electronic diaries, mobile phones, etc. You should follow local policy and protocol.
 
If you work as an independent practitioner you need to consider how you keep information secure, both on computers and/or mobile phones/PDAs. Your security software and systems should meet business and personal data protection requirements. You may use your computer, mobile phone/PDA for both work and personal use. The Data Protection Act 1998 (Great Britain. Parliament 1998b) requires that information is only kept for specified purposes, so your service user data should not be available alongside your own personal information that you access when not working. A solution may be to have different work/private log-ins.

Terminology

For the purposes of these standards, the records kept by occupational therapists are called ‘care records’ or just ‘records’, encompassing records kept, or accessed, in all settings where occupational therapy is provided, whether exclusive to occupational therapy or shared by a team. They include both paper and electronic records.

6. Record keeping

6.1 Your service, or organisation, has clear record keeping procedures that are monitored and reviewed, in line with current legislation

Criteria
6.1.1 Your service, or organisation, has procedures for the creation, use, secure storage and appropriate sharing of records, in line with current legislation
6.1.2 These procedures are monitored and periodically reviewed
6.1.3 Staff, whether clinical or administrative, are appropriately trained so that they are aware of their responsibilities in respect of record creation, use and management
6.1.4 The movement of records is controlled so that a record can be retrieved promptly at any time
6.1.5 There is a system for linking different sets of information about the same person
 

6.2 Your care records are always kept securely and disposed of according to legal requirements and local policy

Criteria
6.2.1 Your storage equipment, systems or facilities keep your records safe from theft, loss, false access or damage
6.2.2 When out of storage, being transported or transferred, your records are always  secure
6.2.3 Your records are never left unattended in a place that is potentially insecure
6.2.4 Your records are only accessible to those who are working directly with your service user
6.2.5 Your records are retained for an appropriate period of time, as defined by their nature, content and purpose
6.2.6 Your records are disposed of in accordance with legal requirements and local guidance
6.2.7 Your workplace diaries are kept securely for a minimum of two years after the end of the year to which the diary relates
6.2.8 Your workplace diaries are destroyed in accordance with legal requirements and local guidance
6.2.9 Any electronic recording systems and diaries, (mobile phones, personal digital assistants, computers), that are used for work purposes adhere to legal and local data protection requirements
6.2.10 You work according to your employer’s security policies and protocols 

6.3 You must comply with any legal requirements and local policies in relation to confidentiality and service user access that are relevant to your work

Criteria
6.3.1 You abide by your duty of confidentiality, subject to statutory and common law exceptions
6.3.2 Service user information is only used for the purpose that it was provided for
6.3.3 Except where the law requires disclosure, your records show evidence that consent is gained before identifiable service user information is shared with people outside of the main care team
6.3.4 You have a protocol for secure information sharing with other organisations
6.3.5 Where mental incapacity does not allow the gaining of consent to share service user information, you follow local policy or protocol
6.3.6 Service users are able to access their own care records in accordance with legislation and local policy
 

6.4 Your care records are fit for purpose

Criteria
6.4.1 Your care records clearly identify the service user throughout, according to local policy and practice
6.4.2 Your care records are legible
6.4.3 Your care records are objective and concise
6.4.4 Your care records are kept in an organised, systematic way
6.4.5 Your care records do not use unexplained acronyms, abbreviations or terminology
6.4.6 All your care record entries are signed, dated (the date the service user was seen and the date the entry was made, if different) and timed
6.4.7 You are clearly identified as the author of your care record entries
6.4.8 There is no indication of tampering in your documents. Any corrections or changes made clearly show the original entry
6.4.9 Your care records are written chronologically
6.4.10 Your care records are written promptly, as soon as practically possible after the activity occurred
6.4.11 The care record entries for students and assistants, for whom you are responsible, meet these requirements
 
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These standards link with:
Code of ethics and professional conduct, section(s) 2.4; 3.7 (COT 2010a)
Doing well, doing better: Standards for health services in Wales, standard(s) 9; 18; 19; 20 (Welsh Assembly Government 2010)
Guidance about compliance: essential standards of quality and safety, outcome(s) 21 (CQC 2010)
National care standards - principles, principle(s) 2 (SCRC 2002)
Quality standards for health and social care, section(s) 5.3.1; 6.3.2; 8.3 (DHSSPS 2006a)
Standards of conduct, performance and ethics, standard(s) 2; 10 (HPC 2008)
Standards of proficiency: Occupational therapists, section(s) 2b (HPC 2007)
The NHS knowledge and skills framework and the development review process - dimension(s) Information and knowledge (DH 2004)