Amid the stress of a working day, it can be easy to forget to update the health records of the patient, but for the benefit of all service users and staff, it’s crucial that all care organisations have an effective record keeping system in place. It is an integral part of care that contributes to improving the health of residents, and the efficiency of the care establishment.
What are healthcare records?
The Data Protection Act 1998 defines a health record as something that consists of information relating to the physical or mental health or condition of an individual, which has been made by or on behalf of a professional in connection with the care of that individual (section 68). They can come in various forms, from electronic care plans, such as those provided by CareDocs, to handwritten notes and monitor charts.
It’s essential that all health records are accurate, up to date and professional. It’s possible that several members of staff will be caring for the same resident, so making sure all records are legible helps to ensure that all members of staff are aware of the latest information. Any notes recorded by carers should be dated and signed, including any discussions with the person receiving care, so that feedback can be obtained from the resident.
Maintaining CQC Compliance
In order to maintain or become CQC Compliant, care homes have to meet the key lines of enquiry set by Care Quality Commission; the care home should be safe, effective, caring, responsive and well-led. Many factors are influential in meeting these requirements, but keeping healthcare records can have a positive influence in fulfilling these standards. Keeping a history of all healthcare records shows that the care provider is organised, responsible and well-led. If for any reason they were required to show evidence of the care they had delivered, the care organisation would have an exhaustive set of documents stating all care provided. This will particularly help the provider meet the ‘effective’ requirements outlined by CQC, as being able to provide documents that show all the treatment and care given to residents will provide proof that the expected care has been delivered. It also helps with accountability, ensuring staff take responsibility for the care given to all residents.
Keeping all resident’s care plans in an accessible place for staff will also help the care provider attain CQC Compliance. The purpose and most important aim of a care establishment is to provide appropriate care and improve the well-being of the receiver. The resident’s care plan outlines all of the care they are entitled to receive, including the dosage of any medication, the frequency and on what dates. This helps the care provider to be well-led, as all staff need to know what they care they are expected to provide to each individual. It reduces the risk of staff confusing the treatments of any residents, and supports continuity of care as all members of staff will be using the same plan to deliver care. This is especially helpful for care establishments who have numerous staff caring for a large number of residents.
Supporting the health of patients
Keeping a history of all the care given to residents will allow members of staff to monitor the progress of residents, and the efficiency of treatments. Monitor charts are particularly helpful at displaying how effective medication is as it shows the how the condition of residents have changed over a period of time. This will allow staff to evaluate the positives and negatives of the care they are providing, giving them an opportunity to assess and improve the quality of care they distribute. The health of all residents is the priority of all care establishments, so being able to view the effect of treatments enables the provider to see a complete record of the patient’s journey through their service.
Record keeping in Care Homes
With CareDocs, all records of each resident are stored digitally. With few clicks, staff can access all of the important information needed, which is stored under logical categories, making it quick and easy to view the relevant information. Carers no longer have to trawl through months of records to find out when the last time a resident had been on an outing, instead it can be quickly found in a short time. Carers can also record in detail every event that happens, ensuring that all records and information are up to date.