Records Management CQC Inspection Alan Ferguson Records Manager

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Records Management CQC Inspection Alan Ferguson: Records Manager & Quality Facilitator Records Management CQC

Records Management CQC Inspection Alan Ferguson: Records Manager & Quality Facilitator Records Management CQC Briefing Dec 2015 V 1 Improving Lives In Our Communities

Records Management covers all aspects of how we deal with information, both clinical and

Records Management covers all aspects of how we deal with information, both clinical and corporate, on a day to day basis. Key requirements that apply to records management include: Care Quality Commission (Regulation 17 – Good Governance) NHS Litigation Authority Risk Management Standards Litigation Authority Information Governance Toolkit Professional Codes of Practice Sources: *Records Management NHS Code of Practice. **Information Governance Toolkit – Corporate Assurance 601/602 Improving Lives In Our Communities

The Care Quality Commission Purpose: They make sure health and social care services provide

The Care Quality Commission Purpose: They make sure health and social care services provide people with safe, effective, compassionate, high-quality care and they encourage care services to improve. Role: • Register care providers. • Monitor, inspect and rate services. • Take action to protect people who use services. • Speak with an independent voice, publishing regional and national views of the major quality issues in health and social care. Improving Lives In Our Communities

Regulation 17 – Good Governance Records related extracts: 17 (c) maintain securely an accurate,

Regulation 17 – Good Governance Records related extracts: 17 (c) maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided Improving Lives In Our Communities

Regulation 17 – Good Governance 17 (d) maintain securely such other records as are

Regulation 17 – Good Governance 17 (d) maintain securely such other records as are necessary to be kept in relation to: (i) persons employed in the carrying on of the regulated activity, and (ii) the management of the regulated activity Improving Lives In Our Communities

Patient / Client records There a number of factors that contribute to effective Record

Patient / Client records There a number of factors that contribute to effective Record Keeping, these include: l Handwriting should be legible l Records should be readable when photocopied or scanned l All entries to a record should be accurately dated, timed and signed, with the full name and designation printed alongside the first entry where this is a written record, and attributed to a named person in an identifiable role for electronic records l Your records should be accurate and recorded in such a way that the meaning is clear l Records should be factual and not include unnecessary abbreviations, jargon, meaningless phrases or irrelevant speculation Continued … Improving Lives In Our Communities

Patient / Client records • You should record details of any assessments and reviews

Patient / Client records • You should record details of any assessments and reviews undertaken and provide clear evidence of the arrangements you have made for future and ongoing care. This should include information given about care and treatment • Records should identify any risks or problems that have arisen and show action taken to deal with them • Where appropriate, the person in your care or their carer, should be involved in the record keeping process • The language that you use should be easily understood by the people in your care • You must not alter or destroy any records without being authorised to do so Remember – “If it is not recorded it didn’t happen!” Source: NMC Record Keeping Guidelines – July 2009 Improving Lives In Our Communities

Feedback from Self Assessment Visits • Ensure that all patient health records are reflective

Feedback from Self Assessment Visits • Ensure that all patient health records are reflective of patients' assessed needs and record the involvement of the patient, carers and family in the care and treatment of the patient • Security of records: ensure that all filing cabinets/cupboards are able to be locked • Ensure records are transported in a secure and safe manner Improving Lives In Our Communities

Feedback from Self Assessment Visits • Ensure all archiving of records is up to

Feedback from Self Assessment Visits • Ensure all archiving of records is up to date. Check areas to ensure there are no “legacy records” from previous services/teams in your areas • Ensure Policies are up to date and current documentation we are using has the SCHT Trust logo and not previous PCT logos • Ensure that computers are locked when unmanned so that no unauthorised person can access it. Tip: To quickly lock your computer use the shortcut keys “ + L” Improving Lives In Our Communities

CQC Information for Staff Improving Lives In Our Communities

CQC Information for Staff Improving Lives In Our Communities

Useful References Improving Lives In Our Communities

Useful References Improving Lives In Our Communities

Improving Lives In Our Communities

Improving Lives In Our Communities