Most care records still get written twice. Once in your head, or scribbled in shorthand while you’re with someone, and once properly, later, when there’s finally a minute to sit down.
That gap is where things go wrong. A detail gets forgotten. A note gets misplaced during a long shift. Something written in a rush gets misread by whoever picks it up next.
CQC and the other regulators aren’t just checking that a record exists. They’re checking that it’s accurate, complete, up to date and genuinely reflects the person it’s about. Records written well after the event, from memory, don’t hold up as well as records made at the time.
That’s the whole idea behind point of care recording. And it’s a lot more achievable than most services think, even with a pen-and-paper habit that’s hard to shake.
What this ebook covers
This is a practical, no-nonsense look at point of care recording, including what it actually is, why regulators rate it so highly, and what’s really involved in doing it properly.
It walks through the honest answer to “can I just use pen and paper?” (yes, technically, but you probably shouldn’t), what CQC’s criteria for a genuinely good digital record actually look like, and where GDPR and the Data Security and Protection Toolkit fit into all of it.
There’s also a set of practical rollout tips, covering everything from dedicated devices to password protection, so you’re not left guessing how to put any of this into practice.
What's inside:
- You’ll understand exactly why writing records from memory or rushed shorthand creates real risk, and why the gap between giving care and recording it is where accuracy quietly falls apart.
- You’ll know what CQC actually means by a “good” record, beyond just accurate: person-centred, legible, complete, up to date and secure.
- Pen and paper gets a straight answer. You’ll see why it can work in theory but rarely holds up once you look at what it takes to do properly.
- Rolling out devices and a digital system brings its own decisions. You’ll get clear, practical steps, from company-issued tablets to password protection and GDPR-compliant access.
- Speech-to-text is starting to show up in care settings. You’ll learn what it’s good for right now and where it still needs a human check.
