Healthcare record keeping policy

To access the corporate record-keeping policy please follow the link: Corporate records policy.

1 Policy summary

This policy is relevant to all individuals who create, access and manage health care records, outlining several legislative requirements concerning how records should be kept and maintained.

There are key principles that employees must demonstrate when creating, accessing, and managing records that are listed for attention in the appendices.

The policy outlines the key steps when creating a record, the information to be obtained and the minimum requirements from trust employees.

All employees should have relevant training to ensure that they meet the requirements outlined in the policy.

There are several other trust policies that are relevant to good record keeping that are referenced and hyperlinked throughout.

2 Introduction

Rotherham Doncaster and South Humber NHS Trust (the trust) must ensure that all healthcare records are created, accessed, managed, and disposed of in accordance with national standards and professional accountability; and are compliant with legal, operational and information governance requirements.

The trust must conform to several legislative requirements, regulations, and standards (opens in new window) that outlines the management of records. These can also be found in the trust’s records management policy.

Healthcare records are an integral part of healthcare practice which is generated on, or on behalf of, all the health employees involved in all aspects of patient care (for example, the care, service and treatment provided) and may need to be accessed by the various employees involved in care delivery.

Healthcare records are generated in a variety of ways including electronic, paper and media storage.

The trust’s healthcare records are primarily held on the electronic patient record (EPR) system which has safeguards in place to protect the integrity, accessibility, and accuracy of the record. The purpose of a healthcare record is to facilitate the care, treatment, and support of patients. To ensure that healthcare records are created in a consistent and professional manner the ‘health care record keeping standards’ (see appendix D) should be always adhered to.

3 Purpose

The aim of this policy is to ensure that all healthcare records generated by health employees are contemporaneous, accurately reflect high standard patient care and support the delivery of evidence-based practice.

This policy outlines the roles, responsibilities, and accountability of trust employees in complying with guidance, legislation, and best practice for keeping records.

4 Scope

This policy covers all types of healthcare records accessed by the trust.

This policy applies to:

all employees working for or on behalf of the trust, including contracted third parties, agency employees, locums, students or trainees, secondees, employees from partner organisations with approved access, visiting employees, researchers, companies providing other services to the trust, for example, information technology (IT) and all volunteers
any trust healthcare records held, maintained, and managed by third parties under contract to the trust

For further information about responsibilities, accountabilities and duties of all employees, please see appendix A.

5 Procedure or implementation

5.1 Quick guide to health care records

5.1.1 Consent

Obtain consent from the patient to access relevant personal information.
Refer to relevant Mental Capacity Act (MCA) guidance where there are concerns regarding capacity.

5.1.2 Generic information

Ensure the relevant information is captured on the generic information template in the 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.

For the principles of effective healthcare record keeping, please see appendix B.

5.2 Creating an electronic healthcare record

When creating an EPR for a patient, several unique patient identifiers will be downloaded automatically from the national summary care records system (Spine).

However, consent must be obtained from the patient to access the following information via the summary care record:

allergies or sensitivities or hypersensitivities
medication

Further guidance regarding consent is available at Information Commissioners Office (opens in new window).

Where the patient lacks mental capacity to give consent, a decision to access additional information should be made in their best interests. See MCA Mental Capacity Act 2005 policy for further guidance or refer to Gillick competency and Fraser guidelines (opens in new window) for patients under the age of 16.

5.3 Minimum data and assessment requirements

There is a minimum data set required for all patients who use trust services, located in the generic information template within the EPR and should be inputted during registration. This information including the patient address must be updated checked and updated regularly during the episode of care.

Following an assessment of a patient, the assessment and outcomes must be recorded in the EPR on the approved templates that have been provided.

The trusts minimum requirements for EPR record are:

an assessment of need
a personalised care and treatment plan, this may be referred to as goals in some departments which links to the assessed needs of the patient
an assessment of risk relevant to the care being delivered, including risk mitigation and management plan
contemporaneous records of healthcare contacts or events which are recorded in the appropriate data entry template and, or questionnaire
records, where possible, should ensure that patient and, or significant other views are reflected and that the care being offered is personalised

The trust has published guidance (staff access only) (opens in new window) to optimise the use of the EPR and encourage best practice. Employee must familiarise themselves with and follow these materials.

Where there are paper records, the healthcare professional is personally responsible and accountable for compliance.

5.4 Delays in completing contemporaneous records

It is expected that all health employees complete records as soon as possible after an event, within 24 hours or less if your local working instructions or arrangements, or key performance indicators’ (KPI’s) require this. All agile workers (those with remote access to the EPR via a digital device) should always be expected to update pertinent aspects of the healthcare record at the time of the visit or when appropriately safe to do so, for example, administration of medicines and specific risks associated with safety.

Any delay entering information into the healthcare records will be based on the health professional’s clinical decision at that time, utilising their knowledge of the patient, the situation, and circumstances.

This decision needs to take into consideration the following:

any risks to patient safety or the safety of others (including employees), should there be a delay in entering information into the healthcare record
any risks to future clinical decision-making if pertinent information is not made available
delays or blockers in accessing other services due to incomplete healthcare records

Where a delay in entering information has occurred, the record must include a reference to the fact that it has been entered retrospectively including a reason for the delay.

5.5 Paper healthcare records

Whilst most healthcare records generated will be held on the EPR system, paper records are still in existence within the trust. Employees should refer to the records management policy for further information relating to storing, tracking, accessing, retention and disposal.

5.6 Copying letters to patients

From 1 August 2016 onwards, all organisations that provide NHS care and, or publicly funded adult social care are legally required to follow the accessible information standard (opens in new window). The Standard sets out a specific, consistent approach to identifying, recording, flagging, sharing, and meeting the information and communication support needs of patients, service users, carers and parents with a disability, impairment, or sensory loss.

Patients have the right to request or receive information held about them under the Data Protection Act 2018 (opens in new window) and the Freedom of Information Act 2000 (opens in new window). This means if patients, consent or agree, letters written about them by one health professional to another should be copied to the patient, or where appropriate, parent, legal guardian or specified other. Further guidance is available from ROAN information sheet 23, quality improvement, best practice for clinical letters (opens in new window).

It is the responsibility of health professional to make patients aware of the fact that they are entitled to receive copies of any letters or documents which relates to them. The patient will need to make an informed preference whether they wish to receive clinician’s letters or not. They will be given a choice on what information they want, who from, the address to which it will be sent and what format (if appropriate). The patient preference should be documented in the generic information template in their EPR and reviewed annually or when the health professional and patient deem it appropriate.

6 Training implications

The training needs analysis can be found in the mandatory and statutory training policy.
All new employees will be made aware of the policy via the induction process and a copy will be available on the website.
All employees must ensure that they familiarise themselves and adhere to the content of this policy and any subsequent changes. Managers must actively ensure that employees who create, manage, transfer, retain or dispose of healthcare records undertake appropriate training opportunities.
All employees handling, accessing, or populating healthcare records will receive record keeping training on induction to the organisation. Training will be appropriate to the individual employee’s role, regularly assessed and refreshed to ensure employees remain appropriately skilled and knowledgeable over time. A minimum of a 3 yearly update is required via the Healthcare record keeping resource (staff access only) (opens in new window).
Ongoing review of the employees record keeping will be captured and evidenced as part of their supervision.
Please note there are a number of EPR guides, videos and system updates available by accessing the clinical systems page (staff access only) (opens in new window) 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 employees, 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 employees 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 staff 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:

9 References

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 employees, 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 employees 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 employees 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 Tendable where requested.

10.1.7 All employees

All employees 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 an employee of the NHS any records created by an employee are public records. All employees must adhere to the relevant trust record keeping and records management policies. In addition, all clinical employees 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 (opens in new window) for guidance on record keeping. Medical employees should refer to the General Medical Council (GMC) Good Medical Practice, Guidance for Doctors (opens in new window) and Allied Health Employees should refer to the Health and Care Professions Council (HCPC) guidance (opens in new window).

10.2 Appendix B Principles of health care records

Accessible to all relevant employees to enable them to carry out their duties. Information must be stored in the correct areas in the 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 employees must be able to read and understand what is written about them. Where health employees wish to use abbreviations, a trust approved list should be consulted in appendix E. Any term can be abbreviated within an individual entry as long as it is written in full the first time.

Factually accurate and relevant. Healthcare records must be concise, factual, and where possible include collateral evidence. Employees should avoid using personal opinions.

Secure. When accessing the electronic patient record, employees 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.

Employees 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 employee member needs to leave the computer screen, this must be locked.

Where an EPR exists, paper records should only be used in the event of system failure and all temporary records must be uploaded into the EPR 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 Tendable 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 employee supervision or PDR processes
Who by: line managers.
Reported to: Care group quality meetings.
Frequency: Monthly.

10.3.2 All complaints received

How: Complaint’s 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 Tendable

How: Ongoing regular audits will be undertaken using Tendable 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 employee depending on the audit type and identified or Tendable trained employee will undertake these audits.
Reported to: Care group quality meetings.
Frequency: Ongoing regular audits will be undertaken using Tendable 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 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)
- staff 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 (staff 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 staff?
- have you checked the demographics? Address, contact numbers etc.
- 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 MDT 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:

good quality
relevant and individualised
evidence patients voice
accurate and complete
timely

10.5 Appendix E Trust approved abbreviations

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	FACE 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(ist)
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	Prefered 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	Staff 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 CQC

Healthcare record keeping audit
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	Yes No, action required or discussion with supervisor
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	Yes No, action required or discussion with supervisor
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	Yes No, action required or discussion with supervisor
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	Yes No, action required or discussion with supervisor
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	Yes No, action required or discussion with supervisor
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	Yes No, action required or discussion with supervisor
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	Yes No, action required or discussion with supervisor
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	Yes No, action required or discussion with supervisor
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	Yes No, action required or discussion with supervisor
Is there evidence that a risk assessment has been fully completed? For example: FACE (mental health services including CAMHS) HoNOS cluster tool (mental health) multifactorial (falls risk assessment) MUST pressure ulcer service specific risk assessments	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	Yes No, action required or discussion with supervisor
Is there evidence that the risk assessment takes into consideration any historical risks where known?	Respective question within respective template	Yes No, action required or discussion with supervisor
Is there a date for when the risk assessment will be reviewed?	Respective question within respective template	Yes No, action required or discussion with supervisor
Is there evidence that the risk assessment was reviewed by this date or sooner if risks changed?	Respective question within respective template	Yes No, action required or discussion with supervisor
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	Yes No, action required or discussion with supervisor
Is it documented how the patient wants to be communicated with from services? letter phone text (SMS) email	Located in the generic information template (red triangle on SystmOne toolbar) under the Accessible information tab	Yes No, action required or discussion with supervisor
Is there evidence of communication being sent to the patient?	Located in the tabbed journal or communications and letters node under the clinical tree	Yes No, action required or discussion with supervisor
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	Yes No, action required or discussion with supervisor
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	Yes No, action required or discussion with supervisor
Are all service specific templates fully completed on SystmOne?	Service specific templates to be identified by service leads	Yes No, action required or discussion with supervisor
Has an entry been made in line with service specific requirements: per shift per appointment per contact following any incidents or intervention	Evidence in tabbed journal of service specific templates such as SOMRAP, handover template	Yes No, action required or discussion with supervisor

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: 4.7.
Unique reference number: 473.
Approved by: Clinical polices review and approval group.
Date approved: 5 March 2024.
Name of originator or author: Head of information quality.
Name of responsible individual: Director of health informatics.
Date issued: 26 September 2024 (minor amendment).
Review date: 31 August 2025.
Target audience: All employees with responsibility for clinical record keeping.

Page last reviewed: September 27, 2024
Next review due: September 27, 2025

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