Record-keeping in health and social care is key to safe and efficient healthcare delivery. It’s the cornerstone for compliance with the GDPR (General Data Protection Regulation) included in the Data Protection Act. Record-keeping empowers care providers to develop, adjust, and implement effective treatment regimes. It also underpins continuity in care and streamlines the professional communication between care providers.
In the UK, institutions rendering healthcare must ensure that health records are accurate and up to date. This includes any NHS-affiliated facility, hospitals, doctors’ rooms, care homes and rehabilitation centres. Digitisation and confidential document shredding are some of the most effective ways to facilitate effective document management in hospitals, trusts and other healthcare environments.
What is record-keeping in healthcare and care homes?
Understanding the importance of record-keeping in health and social care, including care provided in care homes, begins with recognising that these records—whether handwritten or digital—contain sensitive and confidential information. They reflect personal details, physical and mental health observations and diagnoses, diagnostics and prognoses, and medical and surgical interventions. Whether it’s an x-ray, a short handwritten note or a detailed medical history, everything relating to a patient constitutes a health record.
Record-keeping is a systematic process that documents, manages, and maintains all the health information about a patient or resident in a care home. Document storage and secure data destruction form part of this record-keeping process. These facets are also central to the successful and legally compliant management of medical records, including medical histories, care plans, progress reports, and diagnostics. As well as patient or resident records, healthcare facilities also need compliant records for staff, finances, and operations.
Why is record-keeping important in healthcare?
Understanding why record-keeping is important in care homes and how a sound document management strategy establishes proper record-keeping is crucial.
1. Continuity of care
Continuity of care refers to synchronised healthcare. This care can be delivered by one team in one facility or it can be tiered and prolonged, where patients move from one institution to the next and are cared for by different health teams. Accurate healthcare records ensure that everyone involved understands the levels of care required, whether it is between a hospital, radiology or pathology department, step-down facility or care home. In other words, continuity of care means that healthcare providers have the right information so that a patient gets the right treatment, at the right time, in the right place.
Accurate and up-to-date records are the backbone of streamlined care. These documents are at the centre of communication between different healthcare providers and facilities. Effective record-keeping helps prevent medicolegal risks, delays in care, and treatment errors.
2. Patient safety
Record-keeping in health and social care ensures patient safety and high-quality care. These documents reflect relevant prescriptions, dosages, and administration times. They also provide a health and treatment history. This informs caregivers about red flags regarding responses to treatments, which in turn helps to manage and prevent complications.
3. Legal protection
Accurate records ensure compliance with relevant legislation and protect healthcare workers by detailing treatments. These documents are essential evidence when disputes or malpractice claims arise.
4. Regulatory compliance
Healthcare providers must follow relevant legal and ethical regulations, which include proper record-keeping. These guidelines apply to more than taking handwritten or digital notes. They are integral to the entire document management process, from recording and secure document storage to the destruction of records.
5. Seamless communication
Effective, coordinated care relies on accurate patient records. Proper record-keeping facilitates efficient information sharing between different healthcare teams and facilities.
6. Improved decision-making
Accurate healthcare records are the backbone of informed care decisions. Without them, caregivers cannot make the right decisions about diagnoses and treatment options or design on-point care plans that promote patient outcomes.
How to maintain records in health and social care
Determining how to maintain records in health and social care is as important as keeping them.
Follow legal and regulatory guidelines
It is essential to comply with relevant record-keeping legislation, such as the Data Protection Act 2018, GDPR and other healthcare-specific regulations. Doing so ensures that your organisation toes the line when it comes to safeguarding the privacy of patients and the security of their information.
Use digital systems
Digitisation and the use of digital systems streamline record-keeping. In healthcare setups, these technologies pioneer better organisation and access to data. Using a secure document management system also safeguards data against breaches and disasters such as floods or fires.
Considering the sensitive nature and importance of healthcare records, secure document storage and medical record scanning are priorities in any healthcare facility.
Ensure accuracy and completeness
It is paramount that healthcare records are complete, up to date, and contain vital information such as personal details, medical histories, treatments, and care plans. Every healthcare professional has a duty to keep accurate records.
Ensure confidentiality and security
It is pivotal to maintain the confidentiality and security of healthcare records from the time they are created until their legal destruction. To protect the integrity of this data throughout the entire document lifecycle, healthcare institutions must implement secure document storage, medical record scanning, and confidential document shredding.
Learn more about the principles of good record-keeping in healthcare.
How long should records be kept in healthcare and care homes?
In the UK, the law determines for how long organisations must keep their records. The periods differ according to the nature of the documents. For example, the financial records of a limited company must be kept for six years. Let’s take a look at the records applicable to the healthcare industry.
Medical records
Medical records include things such as patient assessments, treatment regimes, prescriptions, and interventions. Generally speaking, it is recommended that these be kept for a minimum of eight years from the date of the last entry or following the discharge or death of a patient. In the case of children, healthcare records should be kept longer than this suggested period.
Employment records
Employment records contain documentation such as employment agreements, training histories, disciplinary measures, and performance assessments. This data should be kept for at least six years after resignation or termination of employment. Employers must refer to the statutory retention periods in the Data Protection Act 2018.
Financial records
Financial records include things such as invoices, payrolls, receipts, auditing, and accounting documents. These records must be kept for at least six years from the end of the applicable financial year. It is, however, crucial to consult the relevant legislation, as some financial documents may have to be retained for longer.
Our document retention policy guide shines more light on the statutory retention period of documents. Patient confidentiality is a prime concern in all healthcare establishments, and confidential document shredding services are a must to ensure legal compliance.
Ensure secure record-keeping in healthcare with Shredall SDS Group
Comprehensive record-keeping, which includes everything from creation to storage to destruction, is fundamental for streamlined, effective, and safe healthcare practices. Shredall SDS Group’s extensive expertise in document management services for hospitals and healthcare trusts makes us the top choice for effective health and social care record-keeping. Get in touch for a free quote today.
