7 Desember 2024

Summary

This video emphasizes the importance of accurate and secure handling of paper and electronic health records within the NHS Foundation Trust. It outlines key responsibilities such as signing and dating entries, ensuring records are clear and legible, and checking for accompanying electronic information. The video highlights the importance of teamwork, secure storage, and proper tracking of records to avoid operational disruptions. It also stresses the legal and ethical implications of mishandling records, including fines and disciplinary actions. Finally, it encourages staff to collaborate and seek guidance from the health records management team to improve record-keeping practices.

Takeaways

• 😀 Health records are both clinical tools and legal documents; failure to follow proper procedures can result in fines, disciplinary actions, or even criminal charges.
• 😀 The NHS Foundation Trust is transitioning to electronic health records, but paper records will still be used for some time.
• 😀 It is everyone's responsibility to ensure the right information is recorded for the right patient, and that it is stored in the right place.
• 😀 When creating a paper record entry, remember to print and sign your name, confirm your designation, include your professional registration number (e.g., GMC or NMC), and note the time and date.
• 😀 Entries must be clear, concise, up-to-date, and legible to ensure accuracy and understanding.
• 😀 Paper records may have an associated electronic record, indicated by a colored sticker; if unsure, check with the IG team or Health Records Management team.
• 😀 Loose sheets must always be filed correctly before being sent to another department or person. Never send loose sheets in an envelope to the health records libraries.
• 😀 Health records must be tracked using the electronic tracking system; missing records can lead to canceled appointments or surgeries.
• 😀 Ensure that health records are securely stored and not left on the floor, in drawers, or on desks at the end of the day or shift.
• 😀 Specialized records may be stored locally or within specific electronic systems; these should be properly registered with the health records department.
• 😀 For records needing archiving, inform the Health Records Management team to arrange appropriate procedures.

Q & A

Why are health records considered both clinical tools and legal documents?

Health records are vital clinical tools for providing effective care. They are also legal documents governed by laws and guidelines, which makes adherence to proper procedures essential. Failure to comply can result in fines, disciplinary actions, dismissal, or even criminal charges.

What is the NHS Foundation Trust transitioning to in terms of health records?

The NHS Foundation Trust is transitioning to electronic health records, although paper records will still be used for a while.

What is the first step when creating an entry in a paper health record?

When creating an entry in a paper health record, you need to print and sign your name, confirm your designation, and include your professional registration number (e.g., GMC or NMC number), along with the time and date of the entry.

What should you do if you're unsure whether there are accompanying electronic health records?

If you're unsure, you should ask IG (Information Governance) or speak to the health records management team to verify whether there are electronic records to accompany the paper documentation.

How should loose sheets be handled in health records?

Loose sheets must always be filed correctly before sending the records to another person or department. Envelopes full of loose sheets should not be sent to the health records libraries.

Why is it important to track health records using electronic tracking systems?

Tracking health records using electronic systems is essential to ensure they are not lost. If records cannot be found, appointments or operations may be cancelled, which can affect patient care.

What are the consequences of improperly storing health records?

Improperly storing health records, such as leaving them on the floor, hidden in drawers, or out on a desk, can lead to security breaches, loss of information, and potential legal and operational issues.

What should you do if health records belong to a specific specialty or are stored locally?

Health records belonging to a specific specialty or stored locally must be registered with the health records department to ensure proper management and tracking.

What is the procedure if health records need to be archived?

If health records need to be archived, you must inform the health records management team so that the appropriate archiving arrangements can be made.

What is the key to improving health records management within the trust?

Improving health records management requires a team effort. Everyone is equally responsible for ensuring the right information is in the right place, and collaboration across departments is essential for maintaining accurate, secure records.