Regulators of health professionals have signed up to new standards for keeping records of team-based care in all formats, including electronic records.
The standards draw together best practice from nursing, midwifery, medicine, dentistry and the professions allied to medicine in four areas: confidentiality and disclosure; communication of information; process principles; and professional and personal knowledge and skills.
Professor Martin Severs, chair of the NHS Information Standards Board, said: “These new standards are not designed to replace the existing processes but rather are a synthesis of those standards that are common to the three regulatory bodies [the General Medical Council (GMC), the Nursing and Midwifery Council (NMC) and the Health Professions Council (HPC)].
“Now there will be a standardised approach to record keeping that embraces best practice from the GMC, NMC and HPC, thus allowing us to fulfil the full potential of the NHS Care Record Service.”
The new standards set out the need for professionals to maintain the confidentiality of all patients and uphold the principles of informed consent and disclosure of confidential information.
They also enshrines the right of patients to know when and how information is recorded about them and how it might be used in the future. In the section on communication, the standards require professionals to ensure information is presented to patients in a way they can understand and underlines the professional’s duty to maintain effective communication with colleagues.
Rules on process principles outlaw – once again – the rude acronyms staff have been known to use in relation to patients. FLK (funny looking kid) and GROLIES (Guardian reader of low intelligence in ethnic skirt) will have no place in the NHS CRS.
They also spell out the need for clear, accurate recording of patient information and lay down the rules for dealing with problems relating to records.
Finally, the standards lay a duty on professionals to keep up to date on policy, law and best practice relating to information and record keeping and to be proficient in using the systems.