Welcome to Derbyshire Community Health Services NHS FT Document Library.
We produce a range of materials to support colleagues in delivering patient care and materials to help communicate trust initiatives.
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Electronic Clinical Record Keeping Guidelines (G333)
All record keeping, using whatever medium should take account of the need to maintain communication between the multi-professional health care team providing care/treatment for the patient/client.
All staff should ensure the correct record is opening by checking three patient identifiers:
• The patients name;
• Date of birth
• And, NHS number/unique patient ID prior to opening the electronic record
The following applies to electronic record keeping:
The principle of confidentiality is equally important when electronic clinical records are being used, including those sent by email, and should comply with the Trust’s code of confidentiality, e-mail policy and information governance policy. Registered clinical staff are professionally responsible for making sure that whatever system they use it is fully secured and managed in such a way that confidentiality is maintained.
Document Categories
- Guidance