FNHC's Best Practices for Clinical & Administrative Staff: Record Keeping Policy, Summaries of Nursing

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Record Keeping Policy

October 2021

FNHC

Document Profile

Document Registration

Added following ratification

Type Policy

Title Record Keeping Policy

Author Mo de Gruchy Category Governance Description To set out the standards and procedures within the organisation which aim to ensure that all members of staff are able to meet legal and best practice in relation to clinical record keeping. Approval Route Organisational Governance Approval Group Approved by

Date approved

Review date 3 years from approval

Document Status

This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet.

Version control / changes made Date Version Summary of changes made Author January 2020

2 Updated to include electronic patients records. Updated to include The Data Protection (Jersey) Law which incorporates GDPR.

Allison Mills

March 2021

3 Reviewed and updated to include additional references

Mo de Gruchy September 2021

3.1 Appendix added ‘Record keeping principles for Child and Family Services’ and mentioned in 2.

Mo de Gruchy

FNHC

1. INTRODUCTION

Clinical record keeping is an integral part of professional practice, designed to inform all aspects of the care process. The use of patient information is an essential aspect of Family Nursing & Home Care (FNHC) and is a key element in supporting the everyday aspects of the delivery of high quality, evidence based health care.

Accurate and effective clinical record keeping is fundamental to high quality patient care. It enables effective communication with other professionals involved in the patient’s care and expresses individual professional accountability and responsibility. It is important that these records are accurate, up to date and easily accessible to those who need to use them.

1.1 Rationale

This policy aims to set out best practice and guidance for all clinical records regardless of their format that currently exist within FNHC and ensure they meet the required standards of:

• Authenticity, integrity and security
• Reliability and confidence in clinical healthcare records/information
• Provide confidence to external inspectors that FNHC’s healthcare records in all formats are robust and reliable

All clinical and administrative staff creating or contributing to the patient record will provide an accurate and timely health record which can determine accountability; facilitate clinical decision making; improve patient care through clear communication of the assessment, treatment and care planning rationale; provide a consistent approach to partnership working; and help in the investigation of complaints or legal proceedings.

1.2 Scope

This policy relates to all clinical records, such as:

• Handwritten and electronic care records
• Fax messages
• Diaries
• Emails
• Text messages
• Incident reports and statements
• Photographs/videos

FNHC

This policy applies to all staff employed by FNHC, including bank staff and students who document in clinical records. 1.3 Role and Responsibilities

Chief Executive Officer

The CEO has overall accountability for the management of records and record keeping within FNHC.

Caldicott Guardian

The Caldicott Guardian is responsible for ensuring that FNHC adheres to the Caldicott Principles when processing patient identifiable information.

Head of Quality, Governance & Care

The Head of Quality, Governance & Care is responsible for the overall development and maintenance of both corporate and health record keeping practices within FNHC, in particular for drawing up guidance for good record keeping practice and promoting compliance with this policy

Operational Leads

Operational Leads must ensure that their staff are trained in the relevant aspects of record keeping and that there is compliance of FNHC policies and procedures. This should be in the form of induction training and relevant updates via the mandatory training schedule.

Individual Responsibility

All FNHC staff have a legal duty of care and are responsible for any records they may create or use. This responsibility is established and defined by law. Every employee’s contract of employment clearly identifies individual responsibilities for compliance with information governance requirements.

2. POLICY

2.1 Purpose of records

 Evidences that policy, process and practice have been followed appropriately, demonstrating professionalism and competency.  Provides the rationale behind professional practice, making it clear how a decision was arrived at and being accountable for why a particular course of action was taken or not taken.  Gives a clear picture of the person’s story, their wishes, views and preferences which can be used by them and / or others to empower and better understand their situation and any care or support needs. (O’Rourke

FNHC

2.5 Security & Confidentiality

All patients/parents will receive a leaflet called ‘How we use your information’ and explains why FNHC collects information about them and how it is used.

All staff have a duty to act in accordance with the data protection legislation in maintaining patient confidentiality.

Patient records must be kept safe at all times. How and where records are stored and who has access to them all impact on maintaining confidentiality of patient records.

All staff should be fully aware of the legal requirements and guidance regarding confidentiality, and ensure their practice is in line with national and local policies FNHC Confidentiality Policy

2.6 Access

A patient’s right of access to their health records (both paper and electronic) is governed by the provisions of the Data Protection (Jersey) Law 2018.

 Patients should be informed that information on their care records may be seen by other people or agencies involved in their care  Patients have the right to ask for their information to be withheld from health professionals.  Patients have a legal right to see their records in the majority of circumstances. FNHC Subject Access Request Policy

2.7 Disclosure

Information that can identify a patient must not be used or disclosed for purposes other than healthcare without the individual’s explicit consent. However, this information can be disclosed if the law requires it, or where there is a wider public interest ie if it will help to prevent, detect, investigate or punish serious crime or if it will prevent abuse or serious harm to others

3. PROCEDURE

3.1 Record Keeping Process

 Records should be completed at the time or as soon as possible after the event within 24 hours unless there are exceptional circumstances. If the notes are written sometime after the event, this must be recorded (NMC 2018).

 Records must be completed accurately and without any falsification and provide information about the care given as well as arrangements for future

FNHC

and ongoing care. Be factual and avoid use of jargon, speculation and abbreviations (also see 3.2).

 Clinical alerts such as allergies or adverse drug reactions must be clearly recorded in the appropriate area of both the paper and electronic record  Consider the persons desired outcomes – their views wishes and feelings (patient voice). Make clear recommendations in relation to actions / inaction, decision making and support which may help the person achieve their outcomes.  Consent to treatment and care must be recorded clearly and carefully in accordance with the FNHC Consent Policy.

 Handwritten records must be signed, timed and dated in permanent black ink. Records should be written clearly and legibly and be readable when photocopied or scanned.

 Each page of a patient's handwritten record should detail the patient name and date of birth or EMIS Number

 Blank spaces or empty lines should not be left between entries, a line should be drawn though any empty space at the end of an entry.

 Any alterations to handwritten records are scored through with a single line and are dated, timed and initialled in such a way that the original entry can still be read clearly. Correction fluid and highlighter pen must not be used.

 Alterations to digital records are traceable within the system. Digital/electronic records must be traceable to the person who provided the care that is being documented.

3.2 Use of Abbreviations

 FNHC endorses the advice of the Nursing and Midwifery Council (NMC 2018) and Royal College of Nursing (RCN 2014) and discourages the use of abbreviations by any member of staff. This will ensure that the information contained in health records and other documents produced by FNHC is clear and understandable to all persons having access to them. If an abbreviation is to be used, it should be written out in full the first time it is used within that particular entry with the abbreviation in brackets.

3.3 Delegation of Record Keeping Process

 Record keeping can be delegated to non-registrants providing direct patient care, so that they can document the care that they have delivered (RCN 2019).

 As with any delegated activity, the nurse needs to ensure that the non- registrant is competent to undertake the activity and that it is in the patient’s best interests for record keeping to be delegated.

FNHC

Justine Le Bon Bell Education Lead 20/04/

5. IMPLEMENTATION PLAN

Action Responsible Person Planned timeline

Email to all staff Secretary/Administration Assistant (Quality and Governance Team) Policy to be placed on organisation’s Procedural Document Library

Secretary/Administration Assistant (Quality and Governance Team) Forms/templates to be uploaded to Central Filing

Head of Information Governance and Systems

6. MONITORING COMPLIANCE

Clinical audit may be used to monitor the standard of recordkeeping. Team Leaders should also monitor the standard of record keeping as part of the oversight of clinical care. The quality of recordkeeping may also be monitored during investigations that involve reviewing patient records.

7. EQUALITY IMPACT STATEMENT

Family Nursing & Home Care is committed to ensuring that, as far as is reasonably practicable, the way services are provided to the public and the way staff are treated reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy document forms part of a commitment to create a positive culture of respect for all individuals including staff, patients, their families and carers as well as community partners. The intention is to identify, remove or minimise discriminatory practice in the areas of race, disability, gender, sexual orientation, age and ‘religion, belief, faith and spirituality’ as well as to promote positive practice and value the diversity of all individuals and communities.

The Values of Family Nursing & Home Care underpin everything done in the name of the organisation. They are manifest in the behaviours employees display. The organisation is committed to promoting a culture founded on these values.

Always:  Putting patients first  Keeping people safe  Have courage and commitment to do the right thing  Be accountable, take responsibility and own your actions  Listen actively  Check for understanding when you communicate  Be respectful and treat people with dignity

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 Work as a team

This policy should be read and implemented with the Organisational Values in mind at all times. See Appendix 1 for the Equality Impact Assessment.

8. GLOSSARY OF TERMS

None

9. REFERENCES

Government of Jersey (2019) The Code of Practice: Professional standards of practice and behaviour for Health and Social Care Support Workers in Jersey. Available: https://carecommission.je/wp-content/uploads/2020/01/Code-of-Practice- Sept-2019-Final.pdf Last accessed 24th^ March 2021

Jersey Care Commission (2019) Standards for Home Care. Available: https://carecommission.je/home-care-standards/ Last accessed 24th^ March 2021

NHSX (2020) Records Management Code of Practice 2020. Available at Records Management Code of Practice 2020 (nhsx.nhs.uk). Last accessed 27th^ April 2021

Nursing and Midwifery Council (2018) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Available at nmc- code.pdf. Last accessed 26th^ April 2021

O’Rourke, L. (2010) Recording in Social Work: not just an administrative task. Bristol, The Policy Press

Royal College of Nursing (2014) EHealth Technology in Practice: Abbreviations and other short forms in patient/client records. Available: https://joinup.ec.europa.eu/sites/default/files/document/2014- 12/Royal%20College%20of%20Nursing%20Guidance%20Document%20- %20Abbreviations%20and%20other%20short%20forms%20in%20patient- client%20records.pdf Last accessed 30th^ March 2021

Royal College of Nursing (2019) Record Keeping: The Facts. Available: https://www.rcn.org.uk/professional-development/publications/pub- Last accessed 29th March 2021

FNHC

Appendix 2 Equality Impact Screening Tool

Stage 1 - Screening

Title of Procedural Document: Record Keeping Policy

Date of Assessment September 2021

Responsible Department

Governance

Name of person completing assessment

Mo de Gruchy Job Title Quality Performance and Development Nurse

Does the policy/function affect one group less or more favourably than another on the basis of :

Yes/No Comments

 Age No

 Disability

Learning disability; physical disability; sensory impairment and/or mental health problems e.g. dementia

No

 Ethnic Origin (including gypsies and travelers) No

 Gender reassignment No

 Pregnancy or Maternity No

 Race No

 Sex No

 Religion and Belief No

 Sexual Orientation No

If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2

Stage 2 – Full Impact Assessment

What is the impact Level of Impact

Mitigating Actions (what needs to be done to minimise / remove the impact)

Responsible Officer

Monitoring of Actions

The monitoring of actions to mitigate any impact will be undertaken at the appropriate level