Records and Record-keeping

Preface; About the author; Acknowledgements; Common terminology and key concepts



1. Health records

1.1 Defining health records

1.2 The purpose of health records

  1.2.1 Clinical purposes

  1.2.2 Non-clinical purposes

1.3 Components of a health record



2. Management of health records

2.1 Confidentiality of health records

  2.1.1 Definition of confidentiality

  2.1.2 Confidentiality: an overview of the law

  2.1.3 Data Protection Act 2018

  2.1.4 Confidentiality and regulation

2.2 Ownership of health records

  2.2.1 NHS employed healthcare practitioners

  2.2.2 Self-employed healthcare practitioners

  2.2.3 Non-NHS employed healthcare practitioners

2.3 Storage of health records

  2.3.1 How to store health records

  2.3.2 Temporary notes

2.4 Retention periods

2.5 Destruction of health records



3. Access to health records

3.1 Patients reading their own health records

3.2 Accessing health records

  3.2.1 Patients

  3.2.2 Relatives

  3.2.3 Healthcare practitioners

  3.2.4 Administrative staff

  3.2.5 Police

  3.2.6 Own health records

3.3 Child patients and access to health records

  3.3.1 The child patient

  3.3.2 Individuals exercising parental responsibility

3.4 Accessing health records after the death of a patient

3.5 Concerns about providing access to a patient's health record



4. The standard for record-keeping

4.1 A standard for maintaining health records

  4.1.1 Legal

  4.1.2 Regulatory

  4.1.3 Employer

  4.1.4 Combined approach

4.2 Features of good record-keeping



5. Practical aspects of health records

5.1 Considerations when writing an entry in a health record

  5.1.1 The right record

  5.1.2 Signing and initialling entries

  5.1.3 Language and style of entry

  5.1.4 Personalised entries

  5.1.5 Ink colour

  5.1.6 Referring to other parts of the health record

  5.1.7 Jargon and abbreviations

  5.1.8 Electronic communications

5.2 Time pressures

5.3 Writing entries for colleagues

5.4 Changing an entry in a health record

5.5 Third party information



6. Best practice in record-keeping

6.1 Best practice pointers

6.2 A process for best practice

6.3 My top tip for best practice in record-keeping



References; Useful resources; Notes