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Why good record keeping matters

For occupational therapistsphysiotherapists and others in Allied Health jobs, good record keeping is a key part of delivering effective patient care. Here are some facts and tips to help you keep your notes in good order.

Making detailed notes is not just about good professional practice. It promotes transparency and accountability, clearly documenting the decisions you have made and actions you have taken. In addition, it's important for effective communication with other health and social care professionals, such as doctors, nurses and social workers. Care records are legal documents and may be used as evidence in an enquiry or a court of law.

The biggest change in record keeping in recent times has been the transition from handwritten to electronic notes. This has had two major benefits: to eliminate issues with illegible handwriting and to make it easier for health professionals to share and access information.

We've put together a few tips for improving your record keeping skills:

1. Create headers

Make sure you label each page or item in your notes with the patient's name, date of birth and a unique identifier, for example a patient reference number.

2. Keep it simple

Try to be as clear as possible in your writing, avoiding or explaining any acronyms and abbreviations

3. Create a timeline

You should add a date and time to all entries in your notes. This could be crucial when you come to review a course of action you have taken

4. Don't delay

It's good practice to write up your notes as soon as possible after any action you have taken, while all the details are still fresh in your mind.

5. Keep records securely

Confidentiality of patient records is obviously very important, so you must ensure that all your notes are protected from unauthorised access. All data stored digitally should require password access and be encrypted.

6. Only amend errors

You should only amend a record if there is an obvious error and you should never change somebody else's notes. If you disagree with something that another health professional has written, you should discuss it with them and explain why you think it should be amended.

All record keeping is now governed by the new General Data Protection Regulation (GDPR), which came into effect on 25 May 2018 and replaces the Data Protection Act 1998. It's worth familiarising yourself with the key requirements of the legislation. More information is available from the Information Commissioner's Office.

Comprehensive record keeping guidance is available from the Royal College of Occupational Therapists and the physiotherapists' professional body, the Chartered Society of Physiotherapy.
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