Keeping records of the care you provide is crucial. You can improve the health of residents, the efficiency of your setting and better comply with CQC regulations, just by having a written reference of the actions and events that took place to look back on and learn from. It’s important to have a proper system in place so nothing is accidentally missed and as much detail can be entered efficiently as possible.

What are healthcare records?

The Data Protection Act 2018 interprets a health record as “personal data relating to the physical or mental health of an individual, including the provision of health care services, which reveals information about his or her health status”. The data can be recorded in various forms, from digital to handwritten notes and monitor charts, with the individual’s consent.

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. For every health care record that is created in the CareDocs software, the time, date and name of carer is saved.

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. Care homes 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 impact 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 you were required to show evidence of the care you had delivered, you would have an exhaustive set of documents stating all care provided. This is particularly helpful in meeting 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 residents’ 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. A resident’s care plan outlines all of the care they are entitled to, 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 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 residents

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 you to see a complete record of the recovery journey through their service.

Record keeping in Care Homes

With CareDocs, all records are stored digitally. With a 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 dig through months of records to find out when the last time a specific event happened. Instead, anything you need can be quickly found in a short time using a range of search functions. Carers can also record detailed notes about everything that happens, emotional responses and upload files and photos, ensuring that all records and information are up to date.

For more information about how CareDocs can make a difference for your care home, call us on 0330 056 3333 or email us at

See more: How to Manage Chronic Illnesses in Care Homes

See more: Person Centred Care Planning – What is it and Why is it Important?

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