To access the corporate record-keeping policy please follow the link: records management policy.
1 Policy summary
This policy applies to all individuals who create, access, or manage healthcare records within the trust. It outlines legislative and regulatory requirements and defines the standards and practices required to maintain accurate, timely, and secure healthcare records.
Colleagues are expected to follow key principles and procedures for creating and maintaining records, as detailed in the appendices. All colleagues must complete appropriate training to meet these requirements. Related trust policies are referenced and hyperlinked throughout this document.
2 Introduction
Rotherham Doncaster and South Humber NHS Trust (the trust) must ensure all healthcare records are managed in line with legal, regulatory, and information governance standards. This includes creation, access, maintenance, and disposal of records in accordance with professional accountability and national standards.
Healthcare records support patient care and are created by or on behalf of healthcare colleagues. These records may be accessed by multiple professionals involved in care delivery and may exist in electronic, paper, or media formats. Most records are managed through the electronic patient record (EPR) system, which includes safeguards to protect their integrity and accuracy.
All records must meet the standards outlined in the healthcare record keeping standards (appendix D).
3 Purpose
This policy ensures healthcare records:
- are contemporaneous, accurate, and reflect high-quality care
- support evidence-based practice
- are managed in accordance with legal and professional standards
- clearly define roles and responsibilities of trust colleagues regarding record keeping
4 Scope
This policy applies to:
- all trust colleagues and those working on its behalf (for example, agency colleagues, students, secondees, volunteers, information technology (IT) support, contracted providers)
- any third-party organisations managing healthcare records under contract with the trust
- all types of healthcare records accessed or maintained by the trust
See appendix A for detailed responsibilities.
5 Procedure
5.1 Quick guide to health care records
5.1.1 Consent
- Obtain consent from the patient to access relevant personal information.
- Refer to the Mental Capacity Act (2005) policy where there are concerns regarding capacity.
5.1.2 Generic information
- Ensure the relevant information is captured on the generic information template in the electronic patient record (EPR).
- Keep personal information up to date.
5.1.3 Minimum content
- Ensure the relevant content is captured using the appropriate templates in a timely way:
- assessment of need
- care plan
- assessment of risk
5.1.4 Timely entries
- Complete records as soon as possible after and event.
- If there is no time to make a full entry, record the pertinent information including medication changes and risk.
- When making a retrospective entry, ensure this is clearly stated including the reason for the delay.
5.1.5 Letters
- Make the patient aware of their right to receive information about their care and treatment.
- Consider the individual accessible need of the patient their family and, or carer.
- Ensure the patient receives the relevant information in line with their personal choices.
Refer to appendix B for principles of effective record keeping.
5.2 Creating an electronic healthcare record
Electronic health records include patient identifiers automatically retrieved from the national summary care record (Spine).
Consent is required to access sensitive data such as allergies and medications. Refer to the Information Commissioners Office for further consent guidance.
For patients lacking capacity, decisions should follow best interest principles see policy or refer to Gillick competency and Fraser guidelines for patients under the age of 16.
5.3 Minimum data and assessment requirements
Capture the minimum data set in the electronic patient record (EPR) at registration and update throughout care. Use approved templates for:
- needs assessment
- personalised care plan or goals
- risk assessment with mitigation plan
- records of patient contact and significant events
- patient or carer views to support personalised care
For children and young people, the record must include relevant family and household context, including parenting capacity, carer involvement, and any known vulnerabilities in the home environment.
Staff must follow internal guidance on electronic patient record usage (staff access only).
5.4 Countersigning
Record keeping can be delegated to health care assistants (HCAs), assistant practitioners (APs), trainee nursing associates (TNAs), nursing associates (NAs), nursing apprentices and students so that they can document their care.
As with any delegated activity, the registered professional needs to ensure that the person is competent to undertake the activity and that it is in the patient’s best interests for record keeping being delegated.
Entries requiring countersignature must be signed by a supervising registered professional who has witnessed the activity or can validate that it took place, in line with the electronic patient record instructions for countersigning. Timeframes and processes should be locally agreed by a ward or service.
For example, if a student nurse completes a functional analysis of care environments (FACE) risk assessment, either the:
- student starts a functional analysis of care environments risk assessment but then nurse reviews and saves it as final version
- student starts and finalises a face risk assessment and then the nurse receives a countersigning task to action in the tabbed journal that the entry has been countersigned
5.5 Delays in completing contemporaneous records
Records should be completed within 24 hours or as specified in local guidance or key performance indicators (KPIs). Agile workers must update records during visits or as soon as safely possible. Clinical judgment must consider:
- risks to patient or colleague safety
- impact on future clinical decisions
- access delays caused by missing information
- retrospective entries must clearly note the delay and the reason
5.5 Paper healthcare records
In the rare occurrence where paper records are used, please refer to the records management policy for further information relating to storing, tracking, accessing, retention and disposal.
5.7 Copying letters to patients
Since 1 August 2016, all NHS and publicly funded social care organisations must comply with the accessible information standard. This ensures patients and carers with disabilities or impairments receive accessible information.
Under the Data Protection Act (2018) and the Freedom of Information Act (2000) patients have rights to access information held about them. With consent, letters between professionals should be copied to the patient, or where appropriate, a legal guardian or specified individual.
Further guidance is available from Responsible Officer and Appraisal Network (ROAN) information sheet 23, quality improvement, best practice for clinical letter.
Document patient communication preferences in the generic information template within the electronic patient record (EPR) and review them at least annually.
6 Training implications
- The training needs analysis can be found in the mandatory and statutory training policy.
- All new colleagues receive training during induction and must familiarise themselves with this policy.
- Managers must actively ensure that colleagues who create, manage, transfer, retain or dispose of healthcare records undertake appropriate training opportunities.
- All colleagues handling healthcare records must complete record keeping training tailored to their role, with a mandatory refresh every three years via the record keeping resource (staff access only).
- Record keeping skills are reviewed during supervision.
- Additional electronic patient record (EPR) training resources are available for colleagues by accessing the clinical systems page (staff access only) on the intranet.
7 Equality impact assessment screening
To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.
7.1 Privacy, dignity and respect
The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.
As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).
7.1.1 How this will be met
All colleagues, contractors and partner organisations working on behalf of the trust must follow the requirements of this policy and other related policies, particularly those relating to information governance. All health colleagues must also meet their own professional codes of conduct in relation to confidentiality.
7.2 Mental Capacity Act
Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.
Therefore, the trust is required to make sure that all colleagues working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.
7.2.1 How this will be met
All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005).
8 Links to any other associated documents
All the documents listed below cover various aspects of record keeping, maintenance and storage and employees should familiarise themselves with:
- Records management policy
- Agile and hybrid working policy
- Care programme approach (CPA) policy
- Mental Capacity Act (2005) policy
- Clinical risk assessment and management policy
- Data protection regulations policy
- Freedom of information and environmental information regulations policy
- Information technology (IT) security policy
- Information governance
- Mandatory and statutory training policy
- Mobile devices, social media, the internet and digital content, appropriate and acceptable use
- Offsite storage procedure
- Consent to care and treatment policy
- Scanning of physical documentation policy
- Electronic patient record (EPR) guidance (staff access only)
9 References
- Care Quality Commission (2021) GP myth buster 8, Gillick competency and Fraser guidelines
- General Medical Council (2022) Keeping records
- GOV.UK (2018) Data Protection
- Health and Care Professions Council (2022) Record Keeping
- Information Commissioner’s Office (2022) Consent
- Legislation GOV.UK (1990) Access to Health Records Act (1990)
- Legislation GOV.UK (2000) Freedom of information Act (2000)
- Legislation GOV.UK (2005) Mental Capacity Act (2005)
- NHS (2022) Accessible Information Standard
- NHS (2022) Responsible Officer and Appraisal Network (ROAN) information sheet 23, quality improvement, best practice for clinical letter
- Nursing and Midwifery Council (2022) The Code
- Clinical Systems (staff access only)
- Guidance and videos (staff access only)
10 Appendices
10.1 Appendix A responsibilities, accountabilities, and duties
10.1.1 The trust
The trust has a duty of care and a duty of confidentiality to ensure that all aspects of healthcare record keeping are properly managed. The trust must adhere to the legislative, statutory, and good practice guidance requirements relating to healthcare records management.
10.1.2 The chief executive
The chief executive has overall accountability and responsibility for healthcare records within the trust. This function is delegated to the executive medical director and the executive director of nursing and allied health colleagues, who are responsible for driving high quality standards of healthcare record keeping.
10.1.3 The trust executive medical director
The trust’s executive medical director plays a key role in ensuring that NHS and partner organisations comply with current national guidance and relevant legislation regarding the handling and safeguarding of patient identifiable information. The Caldicott guardian will advise colleagues on matters relating to the management of patient identifiable information, for example where issues such as the public interest conflicts with duties such as maintaining confidentiality.
10.1.4 Senior managers
Senior managers of the trust are responsible for the quality of the healthcare records that are generated by all trust colleagues to ensure patient safety and quality service delivery.
10.1.5 Head of information management and business intelligence
Head of information management and business intelligence will advise the trust on how to maintain an efficient and effective patient information system, which complies with all the data collections required within the NHS.
10.1.6 The clinical audit team
The Clinical Audit team will support care groups through local place-based audit programmes and local review audit system where requested.
10.1.7 All colleagues
All colleagues of the trust are responsible for any records which they create or use. This responsibility is established at, and defined by, the Public Records Act (1958). As a colleague of the NHS any records created by a colleague are public records. All colleagues must adhere to the relevant trust record keeping and records management policies. In addition, all clinical colleagues have a professional responsibility and accountability to comply with record keeping standards and protocols specific to their professional codes of conduct or practice, for example, nurses, midwives and nursing associates should refer to the Nursing and Midwifery Council Code for guidance on record keeping. Medical colleagues should refer to the General Medical Council (GMC) good medical practice, guidance for doctors and Allied Health Colleagues should refer to the Health and Care Professions Council (HCPC) guidance.
10.2 Appendix B principles of health care records
Accessible to all relevant colleagues to enable them to carry out their duties. Information must be stored in the correct areas in the electronic patient record (EPR) and entered via approved data entry formats where they exist.
Understandable, clear, and concise. Healthcare records must avoid the use of jargon and technical terminology as the patient or other colleagues must be able to read and understand what is written about them. Where health colleagues wish to use abbreviations, a trust approved list should be consulted in appendix E. Any term can be abbreviated within an individual entry if it is written in full the first time.
Factually accurate and relevant. Healthcare records must be concise, factual, and where possible include collateral evidence. Colleagues should avoid using personal opinions.
Secure. When accessing the electronic patient record, colleagues must ensure that this is done via smart card and personal identification number (PIN). Username and passwords should only be if there are issues with the smart card software. Passwords and PINs should not be written down or shared.
Colleagues must ensure that their computer screens cannot be seen by others who should not normally be privy to patient information, which may require the use of a privacy screen or other suitable products. If for any reason the colleague member needs to leave the computer screen, this must be locked.
Where an electronic patient record exists, paper records should only be used in the event of system failure and all temporary records must be uploaded into the electronic patient record once the system is restored.
10.3 Appendix C monitoring arrangements
10.3.1 Employee practice standards or competence
- How: where an audit is not available on local audit review system the assessment and management of professional competency will be monitored at a local level through the following arrangements:
- monthly audit of patient records (an example template is available in appendix F)
- individual colleague supervision or professional development review (PDR) processes
- Who by: line managers.
- Reported to: care group quality meetings.
- Frequency: monthly.
10.3.2 All complaints received
- How: complaints procedure.
- Who by: service managers or matrons in conjunction with the Complaints team.
- Reported to: the relevant care group leadership and quality group.
- Frequency: quarterly.
10.3.3 Local audit review system
- How: ongoing regular audits will be undertaken using local audit review system by care groups to ensure that ongoing record keeping is of the required quality. This will help to inform local audit programmes and to measure the impact of actions taken, supporting improvement activity.
- Who by: ward or team managers, service managers and other clinical colleague depending on the audit type and identified, or local audit review system trained colleague will undertake these audits.
- Reported to: care group quality meetings.
- Frequency: ongoing regular audits will be undertaken using local audit review system by care groups to ensure that ongoing record keeping is of the required quality. This will help to inform local audit programmes and to measure the impact of actions taken, supporting improvement activity.
10.4 Appendix D health care record keeping standards
Top tips to support our improvement work to ensure good quality records, care and treatment plans and clinical risk assessments.
10.4.1 What makes a good quality record
- Right login, are you logged in as yourself?
- Right record, are you in the correct patient record? Double check before you start adding an entry Right module or unit, are you in the right module or SystmOne hub (TPP) unit?
- Right place, are you in the correct template in the record for this piece of information?
- Right time:
- are the entries or detail in the correct order chronologically where possible?
- have they been entered in a reasonable timeframe after contact with the patient? If not, have you explained why in the record?
- Right detail included, for example:
- allergy status
- next of kin
- language
- documented fully that a letter hash as not been shared (check generic information tab)
- colleague members and other attendees documented names and job roles in full
- actions and reasoning clear and relevant to the
entry
- Right wording used:
- wording appropriate, clear and factual and relevant
- opinion, jargon and speculation free
- free from abbreviations, or where used, to be written in full in first instance
- enough information to make the entry clear and to the point
- avoid confusion (colleague or patient)
- Right communication identified:
- nominated person to contact if not the patient themselves-carer or family member
- declined to share information with carer or family members, is this clear to other colleagues?
- have you checked the demographics? Address, contact numbers et cetera
- alerts or flags
- correct format identified
10.4.2 Care and treatment planning
- Ensure your patient has a current care and treatment plan, depending on the service you work in this will be captured using core care plan or goal functionality or via a bespoke template.
- Please ensure you routinely produce care, and treatment plans collaboratively with your patients capturing their views and preferences in the narrative-avoid jargon and abbreviations.
- Have you offered a copy of the care and treatment plan to your patient?
- For services who create care and treatment plans you should complete the “RDASH care plan consent, patient or family or carer template” within the care plan folder on the clinical tree, to indicate the patient has agreed the care and treatment plan and whether they have accepted or declined a copy.
10.4.3 Clinical risk assessment
- Ensure your patient has an up-to-date clinical risk assessment. The current process supports a stepped approach to risk assessment, it means all patients are expected to have a screening risk assessment, with further enhanced assessment only required if and where areas of higher risk are noted?
- Remember when you have completed your risk assessment you should save as final version, which can’t be edited.
- Ensure your risk assessment is individual to your patient and is co-produced with your patient, their carer and wider multi-disciplinary team where appropriate, it should include:
- meaningful activities to manage risk
- positive risk management
- has a strengths-based approach which is realistic and achievable
In summary, our record keeping should be “GREAT”:
- G: good quality
- R: relevant and individualised
- E: evidence patients voice
- A: accurate and complete
- T: timely
10.5 Appendix E trust approved abbreviations
| Abbreviation | Definition |
|---|---|
| A&E | Accident and emergency |
| ABPI | Ankle brachial pressure index |
| ACE | Angiotensin-converting enzyme |
| Ace III | Addenbrookes cognitive examination III |
| ACP | Advanced care practitioner |
| ACT | Acceptance commitment therapy |
| ACTH | Adrenocorticotropic hormone |
| A-DES | Adolescent dissociative experiences scale |
| ADHD | Attention deficit hyperactivity disorder |
| ADL(S) | Activities of daily living |
| ADRT | Advance decision to refuse treatment |
| AED | Anti-epileptic drugs |
| AF | Atrial fibrillation |
| AHP | Allied health profession |
| AIDS | Acquired immunodeficiency syndrome |
| AKI | Acute kidney injury |
| ALP | Alkaline Phosphatase |
| ALT | Alanine Aminotransferase |
| AMH | Adult mental health |
| AMHP | Approved mental health professionals |
| AN | Antenatal |
| ANP | Advanced nurse practitioner |
| APTT | Activated partial thromboplastin time |
| ARMS | At risk mental state |
| AROM | Active range of movement |
| ASD | Autism spectrum disorder |
| ASQ | Ages and stages questionnaire |
| AST | Aspartate Aminotransferase |
| AP | Attendant propelled |
| AWOL | Absent without leave |
| BA | Behavioural activation |
| BAPEN | British association for parenteral and enteral nutrition |
| BER | Beyond economic repair |
| BBV | Blood-borne virus |
| BG | Blood glucose |
| BGT | Balloon gastrostomy tube |
| BI | Best interests |
| BiPAP | Bi-level positive airway pressure |
| BMI | Body mass index |
| BNF | British National Formulary |
| BNP | B-type natriuretic peptide |
| BO | Bowels open |
| BP | Blood pressure |
| BPH | Benign prostatic hyperplasia |
| BPM | Beats per minute |
| BPSD | Behavioural and psychological symptoms of dementia |
| C&YP | Children and young people |
| C. diff | Clostridium difficile |
| CABG | Coronary artery bypass graft |
| CAMHS | Child and adolescent mental health services |
| CAT | Cognitive analytical therapy |
| CBT | Cognitive behavioural therapy |
| CCE | Child criminal exploitation |
| CCG | Clinical commissioning group |
| CCN | Children’s community nurse |
| CCP | Cyclic Citrullinated peptide |
| CDOP | Child death overview panel |
| CEDS | Children’s eating disorders |
| CEOP | Child exploitation and online protection |
| CFT | Compassion focused therapy |
| CHC | Continuing healthcare |
| CHD | Coronary heart disease |
| CIC | Children in care |
| CIN | Child In need |
| CKD | Chronic kidney disease |
| CMHT | Community Mental Health team |
| CNN | Community nursery nurse |
| CNS | Clinical nurse specialist |
| COPD | Chronic obstructive pulmonary disease |
| COSHH | Control of substances hazardous to health |
| COVID-19 | Coronavirus disease |
| CP | Child protection |
| CPA | Care programme approach |
| CPAP | Continuous positive airway pressure |
| CPR | Cardio-respiratory resuscitation |
| CQC | Care Quality Commission |
| CRIES | Child revised impact of events scale |
| CRP | C-reactive protein |
| CRT | Cognitive rehabilitation therapy |
| CSCI | Continuous subcutaneous infusion |
| CSE | Child sexual exploitation |
| C-section | Caesarean section |
| CSPCT | Community Specialist Palliative Care team |
| CSPR | Child safeguarding practice review |
| CST | Cognitive stimulation therapy |
| CSU | Catheter stream urine sample |
| CT | Computed tomography |
| CWP | Children’s well-being practitioner |
| CYPs | Children and young people’s services |
| D&A | Drug and alcohol service |
| DASH | Domestic abuse, stalking and honour based violence |
| DBS | Dried bloods spot test |
| DBT | Dialectical behavioural therapy |
| DBTH | Doncaster and Bassetlaw Hospital |
| DDP | Dyadic developmental psychotherapy |
| DHR | Domestic homicide review |
| DKR | Diabetic ketoacidosis |
| DMBC | Doncaster Metropolitan Borough Council |
| DN | District nurse |
| DNA | Did not attend |
| DNACPR | Do not attempt cardio-respiratory resuscitation |
| DoLS | Deprivation of liberty safeguards |
| DRE | Digital rectal examination |
| DRF | Digital removal of faeces |
| DRI | Doncaster Royal Infirmary |
| DSN | Diabetes specialist nurse |
| DVLA | Driving and vehicle licensing agency |
| DVT | Deep vein thrombosis |
| ECG | Electrocardiogram |
| ECHO | Echocardiogram |
| ED | Emergency department |
| EDD | Expected date of delivery |
| EDTA | Ethylene-diamine-tetra-acetic acid |
| EEG | Electroencephalogram |
| eGFR | Estimated glomerular filtration rate |
| EHCP | Education health care plan |
| ELR | Elevating leg rests |
| EMDR | Eye movement desensitisation reprocessing |
| EOL | End of life |
| EOLT | End of Life team |
| EPIC | Electric powered indoor wheelchair |
| EPIOC | Electric powered indoor outdoor wheelchair |
| ESR | Erythrocyte sedimentation rate |
| EUPD | Emotionally unstable personality disorder |
| EVOLVE | Local authority multi agency child exploitation service |
| FACE | Functional analysis of care environments risk assessment |
| FAROM | Full active range of movement |
| FBC | Full blood count |
| FEP | Free erythrocyte protoporphyrin |
| FGM | Female genital mutilation |
| FII | Fabricated or induced illness |
| FP10 | Prescription form |
| FSW | Family support workers |
| FT | Family therapy |
| GAD2 | Generalized anxiety disorder 2 questions |
| GAD5 | Generalized anxiety disorder 5 questions |
| GCSF | Granulocyte colony stimulating factor |
| GGT | Gamma-glutamyl transferase |
| GLP1a | Glucagon like peptide 1 agonist |
| GMC | General medical council |
| GP | General practice or practitioner |
| Hb | Haemoglobin |
| HbA1C | Haemoglobin with glucose irreversibly bound |
| HCA | Health care assistant |
| HCAI | Healthcare acquired infection |
| HCC | Hepatocellular carcinoma |
| Hct | Haematocrit |
| HDL-cholesterol | High-density lipoprotein cholesterol |
| Hep B | Hepatitis B virus |
| Hep C | Hepatitis C virus |
| HF | Heart failure |
| HIV | Human immunodeficiency virus |
| HNA | Health needs assessment |
| HOOF | Home oxygen order form |
| HPV | Human papillomavirus |
| HR | Heart rate |
| HR(S) | Hour(s) |
| HRT | Hormone replacement therapy |
| HTT | Home Treatment team |
| HV | Health visitor |
| Hyper | Hyperglycaemia |
| Hypo | Hypoglycaemia |
| IC | intermediate catheterisation |
| ICB | Integrated care board |
| ICD | Implantable cardioverter defibrillator |
| ICPC | Initial child protection case conference |
| ICS | Integrated care system |
| IDDSI | International dysphagia diet standardisation Initiative |
| IDVA | Independent domestic violence advisors |
| IHD | Ischaemic heart disease |
| IHORM | Initial home oxygen risk mitigation form |
| IHTT | Intensive Home Treatment team |
| IMCA | Independent mental capacity advocate |
| IMHA | IMHA independent mental health advocate |
| Imms | Immunisations |
| INR | International normalized ratio |
| IPC | Infection prevention and control |
| IPOC | Individual plan of care |
| IPT-A | Interpersonal therapy for adolescents |
| IPU | Inpatient unit |
| IR | Immediate release (medications) |
| IR1 | Incident reporting |
| IRO | Independent review officer |
| ISC | intermittent self catheterisation |
| IT | Information technology |
| JTAI | Joint targeted area inspection |
| LA | Local authority |
| LAB | Laboratory |
| LAC | Looked after child |
| LADO | Local authority designated officer |
| LASER | Light amplification by stimulated emission of radiation |
| LD | Learning disability |
| LDL-cholesterol | Low-density lipoprotein cholesterol |
| LFD | Lateral flow device |
| LFT’s | Liver function tests |
| LI-CBT | Low intensity cognitive behavioural therapy |
| LLR | Lessons learnt review |
| LOS | Length of Stay |
| LPD | Low profile device |
| LPoA | Lasting power of attorney |
| LPS | Liberty protection safeguards |
| LTBI | Latent tuberculosis infection |
| LTC | Long term condition |
| LUNSERS | Liverpool University neuroleptic side effect rating scale |
| LUTS | Lower urinary tract symptoms in men |
| LVSD | Left ventricular dysfunction |
| MACE | Multi agency child exploitation meeting |
| MAOI | Monoamine-oxidase inhibitor |
| MAPPA | Multi-agency public protection arrangements |
| MAPRIM | Male acute painful retention in men |
| MARAC | Multi-agency risk assessment conference |
| MASH | Multi-agency safeguarding hub |
| MBT | Mentalization based therapy |
| MCA | Mental Capacity Act |
| MCA1 | Record or evidence of assessment of capacity |
| MCA2 | Record or evidence the best interest decision (where a patient lacks capacity) |
| MCV | Mean cell volume |
| MDR TB | Multi drug resistant tuberculosis |
| MDT | Multi-disciplinary meeting |
| MHA | Mental Health Act |
| MHLT | Mental Health Liaison team |
| MHRA | Medicines and healthcare products regulatory agency |
| MI | Myocardial infarction |
| MMR | Measles, Mumps, and Rubella |
| MND | Motor neurone disease |
| MoCA | Montreal cognitive assessment |
| MRI | Magnetic resonance imaging |
| MRSA | Methicillin-resistant Staphylococcus aureus |
| MS Teams | Microsoft Teams |
| MSE | Mental status examination |
| MSU | Midstream specimen of urine |
| MTPJ | Metatarsal phalangeal joint |
| MUST | Malnutrition universal screening tool |
| Na | Sodium |
| NBM | Nil by mouth |
| NCEPOD | National confidential enquiry into patient outcome and death |
| NEPSY-II | A developmental neuropsychological assessment, version 2 |
| NEWS | National early warning score |
| NEWS2 | National early warning score 2 |
| NG Tube | Nasogastric tube |
| NHS | National Health Service |
| NICE | National Institute for Health and Care Excellence |
| NIV | Non-invasive ventilation |
| NLaG | Northern Lincolnshire and Goole NHS Foundation Trust |
| NLC | North Lincolnshire council |
| NMP | Non-medical prescriber |
| NN | Nursey nurse |
| Nocte | Every night |
| NoF | Neck of femur |
| NRT | Nicotine replacement therapy |
| NSAID | Non-steroidal anti-inflammatory drug |
| NSCAP | Northern School of Child and Adolescent Psychotherapy |
| NSTEMI | Non ST elevation myocardial infarction |
| O2 sats | Oxygen saturations |
| OC | Obsessions and compulsions |
| OCD | Obsessive compulsive disorder |
| ODN | operational delivery network |
| OOH | Out of hours |
| ONS | Oral nutritional supplements |
| OPAT | Outpatient parenteral antibiotic therapy |
| OPD | Outpatient department |
| OPMH | Older peoples mental health |
| OT | Occupational therapist |
| PA | Physicians associate |
| PACE | Playfulness, acceptance, curiosity and empathy |
| PALS | Patient advice and liaison service |
| PCI | Percutaneous coronary intervention |
| PCR | Polymerase chain reaction |
| PE | Pulmonary embolism |
| PEG | Percutaneous endoscopic gastrostomy |
| PET scan | Position emission tomography |
| PFA | Pelvic floor assessment |
| PFE | pelvic floor exercises |
| PHE | Public Health England |
| PHQ2 | Patient health questionnaire 2 questions |
| PHQ9 | Patient health questionnaire 9 questions |
| PHSIO | Physiotherapy or physiotherapist |
| PICU | Psychiatric intensive care unit |
| PIP | Personal independence payment |
| PIPOT | Persons in a position of trust |
| PND | Paroxysmal nocturnal dyspnoea |
| POCT | Point of care test |
| POON’s | Paediatric outreach oncology nurses |
| PPD | Preferred place of death |
| PPE | Personal protective equipment |
| PPI | Proton pump inhibitor |
| PPM | Permanent pacemaker |
| PROM | Passive range of movement |
| PSA | Prostate-specific antigen |
| PTH | Parathyroid hormone |
| PTSD | Posttraumatic stress disorder |
| PTT | Partial thromboplastin time |
| PWB | Personal wheelchair budget |
| QNA | Qualified nursing associate |
| QOF | Quality and outcomes framework |
| RA | Rheumatoid arthritis |
| RAG | Red, amber, green |
| RBC | Red blood cells |
| RCADS | Revised child anxiety and depression scale |
| RCPC | Review child protection conference |
| RDaSH | Rotherham, Doncaster and South Humber |
| ReSPECT | Recommended summary plan for emergency care and treatment |
| RFS | Refeeding syndrome |
| RGN | Registered general nurse |
| RIDDOR | Reporting of injuries, diseases and dangerous occurrences regulation |
| RIP | Rest in peace |
| RMBC | Rotherham Metropolitan Borough Council |
| RMN | Registered mental health nurse |
| RNLD | Registered learning disabilities nurse |
| RR | Respiration rate |
| RSV | Respiratory syncytial virus |
| S(number) | Section (insert relevant section number) for example S2, equals section 2 |
| SAB | Safeguarding adult board |
| SALT | Speech and language therapy |
| SAR | Safeguarding adult review |
| SCF | Semi compressed felt |
| SCH | Sheffield Children’s Hospital |
| SD | Syringe driver |
| SENCO | Special educational needs and disability coordinator |
| SEND | Special educational needs and disability |
| SGH | Scunthorpe General Hospital |
| SGLT2i | Sodium-glucose transport protein 2 inhibitor |
| SI | Serious incident |
| SIADH | Syndrome of inappropriate anti-diuretic hormone |
| SIDS | Sudden infant death syndrome |
| SLE | Systemic Lupus Erythematous |
| SMS | Short message service |
| SN | Colleague nurse |
| SOAD | Second opinion appointed doctor |
| SOMRAP | Subjective objective medication risk analysis plan |
| SOP | Standard operating procedure |
| SP | Self-propelled |
| SPA | Single point of access |
| SPC | Summary of product characteristics |
| SPOC | Single point of contact |
| SpR | Specialist registrar |
| SR | Sinus rhythm |
| SSN | Special school nurse |
| ST | Specialty trainee (rotational training doctor) |
| STEMI | ST elevation myocardial infarction |
| StN | Student nurse |
| STOMP | Stopping over medication of people with a learning disability, autism or both |
| STPP | Short term psychodynamic psychotherapy |
| SVR | Sustained virological response |
| T/C | Telephone Call |
| TA | Therapy assistant |
| TAF or TAC | Team around family or child |
| TAP | Thorax, abdomen and pelvis |
| TB | Tuberculosis |
| tel | Telephone |
| TENS | Transcutaneous electrical nerve stimulation |
| TIA | Transient ischemic attack |
| TNA | Trainee nurse associate |
| TRFT | The Rotherham Foundation Trust |
| TRS | Trauma and resilience service |
| TSH | Thyroid stimulating hormone |
| TTO | To take out |
| TV | Television |
| TWOC | Trial without catheter |
| TXT | Text |
| U&E(s) | Urea and electrolytes |
| UBB | Unborn baby |
| USS | Ultrasound scan |
| UTI | Urinary tract infection |
| VTE | Venous thromboembolism |
| VTS | Vocational training scheme (rotational training doctor, GP) |
| W/S | Walking stick |
| WAIS | Wechsler’s adult intelligence scale, fourth UK edition |
| WBC | White blood cells |
| WCC | White cell count |
| WISC | Wechsler intelligence scale for children |
| WS | Wells score |
| WZF | Wheeled Zimmer frame |
| XDR TB | Extensively drug resistant tuberculosis |
| YAS | Yorkshire Ambulance service |
| YMARAC | Young-persons multi-agency risk assessment conference |
| YOS | Youth offending service |
| ZF | Zimmer frame |
Further abbreviations available in the safe and secure handling of medicines manual and the records management policy.
10.6 CPR Appendix F health care record keeping audit Care Quality Commission
| Criteria | Where is this located | Yes or no |
|---|---|---|
| Are any abbreviations in the patient record included within the approved abbreviation list attached to the updated healthcare record keeping policy | Appendix E of the healthcare records policy |
|
| Has it been recorded in the patient record whether the patient has any sensitivities or allergies, or no known allergies recorded. Note, this should not be blank | Located under the sensitivities and allergies node in the clinical tree |
|
| If prescribed medication is their evidence of medication monitoring for side effects, templates on SystmOne to be completed where available to the required timeframes | Located in specific medication template (Lithium or antipsychotic for example) or evidenced within tabbed journal under medication related entries |
|
| Is there a care plan or a plan of care which captures the patients’ identified needs and care and treatment plans | Located in the care plan folder under the clinical tree |
|
| Does the care plan have a date for when this will be reviewed or when this will be completed by? | Located in the care plan folder under the clinical tree |
|
| Is there evidence that the patient has been involved in planning their care plan or plan of care? | Located in the core care plan functionality under the clinical tree as agreement by patient in the drop-down menu |
|
| Does the patient consent to relatives or carers being involved in their care? | Located in the care plan consent template within the care plan folder under the clinical tree |
|
| Where appropriate and consent given is there evidence that carers, family or significant others were involved in the care plan or plan of care? | Located in the core care plan functionality under the clinical tree as agreement by respective person in the drop-down menu |
|
| Is there evidence that the patient was offered a copy of their care plan or given information about what would be provided by the service? | Located in the care plan consent template within the care plan folder under the clinical tree |
|
Is there evidence that a risk assessment has been fully completed? For example:
|
Located in respective risk template in SystmOne. As some of these might be questionnaires, only the title of the document will be visible in the tabbed journal, but full details can be viewed in the questionnaire’s node under the clinical tree |
|
| Is there evidence that the risk assessment takes into consideration any historical risks where known? | Respective question within respective template |
|
| Is there a date for when the risk assessment will be reviewed? | Respective question within respective template |
|
| Is there evidence that the risk assessment was reviewed by this date or sooner if risks changed? | Respective question within respective template |
|
| Is it documented that the patient wishes to receive communication from the service? | Located in the generic information template (red triangle on SystmOne toolbar) under the accessible information tab |
|
Is it documented how the patient wants to be communicated with from services?
|
Located in the generic information template (red triangle on SystmOne toolbar) under the accessible information tab |
|
| Is there evidence of communication being sent to the patient? | Located in the tabbed journal or communications and letters node under the clinical tree |
|
| Is it documented that the patient needs communication or information in line with the accessible information standard? | Located in the generic information template (red triangle on SystmOne toolbar) under the accessible information tab |
|
| Is it documented if the patient wants communication in a different language other than English? (including British Sign Language) | Located in the generic information template (red triangle on SystmOne toolbar) under the accessible information tab |
|
| Are all service specific templates fully completed on SystmOne? | Service specific templates to be identified by service leads |
|
Has an entry been made in line with service specific requirements:
|
Evidence in tabbed journal of service specific templates such as subjective objective medication risk analysis plan (SOMRAP) handover template |
|
Discuss an action plan and any required training needs as a result of this audit, who will do what by what timeframe and when will this be reviewed.
Specific measurable achievable realistic timely, action plan (example below):
- clinician 1 will book on risk assessment training
- clinician 1 will be shown risk assessment template on SystmOne
- clinician 1 will update risk assessment with supervisor support, including carer involvement and discuss with the patient and give a copy to the patient by 2 June 2023. To review full caseload in next supervision
Document control
- Version: 5.
- Unique reference number: 473.
- Approved by: digital transformation group.
- Date approved: 12 August 2025.
- Name of originator or author: head of information quality.
- Name of responsible individual: director of health informatics.
- Date issued: 11 September 2025.
- Review date: 30 September 2028.
- Target audience: all colleagues with responsibility for clinical record keeping.
Page last reviewed: September 11, 2025
Next review due: September 11, 2026
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