Clinical Record Keeping Policy and Standards (P6)
This policy aims to ensure that the clinical records made by staff are fit for purpose and of a quality that provide for objective, accurate, current and comprehensive information that supports and enables the best clinical care and treatment for the patient/client. This policy has incorporated a range of best practice and related legislative requirements to outline the organisations expectations for clinical record keeping standards, both on paper and electronically. The policy provides support to the organisation in meeting its statutory and legal obligations as laid down by the Records Management: NHS Code of Practice 2016; Data Protection Act 1998 section 7, General Data Protection Regulation 2018 and relevant professional bodies.
The policy also identifies the standards expected of all registered and non-registered staff. It sets a minimum standard, which will be applicable to all patient settings, including community clinics and inpatient areas. This policy does not replace standards set by professional organisations, but is complementary to them and should be used in conjunction with them.
Policy Categories
- Clinical