2.3. Maintain records that are up-to-date, complete, accurate and legible

Course- Level 3 diploma in care (RQF)

Unit 9 – Promote Effective Handling of Information in Care Settings

L.O 2 – Be able to implement good practise in handling information

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2.3. Maintain records that are up-to-date, complete, accurate, and legible

In order to maintain records that are up-to-date, complete, accurate, and legible, it is important for care settings to promote effective handling of information. This means having a system in place for recording and tracking information, as well as ensuring that all staff members are properly trained in how to use the system.

It is also important to have regular reviews of records both during and after patient care in order to ensure accuracy and completeness. By implementing these measures, care settings can help ensure that patients receive the best possible care and that all relevant information is available when needed.

Up-to-date Maintain records:

Records must be kept up-to-date to ensure that all necessary information is included and any discrepancies or omissions will be addressed during the review process. Reviewing records at least once before discarding old records ensures that there are no loose ends and that all relevant information can be found in one place. This ensures that care is consistent and thorough and that the care setting is in compliance with federal and provincial laws.

Complete maintain records:

In addition to being up-to-date, records must be complete. This means that information concerning a patient’s past and present needs, as well as all of a patient’s medications and treatments during a hospital stay, must be recorded in the medical record. In cases where an explanation is not necessary or appropriate, it may be helpful for care settings to use a code or symbol for sensitive information rather than recording the information itself. Completing all records as completely as possible can also help ensure that care is consistent and thorough, as well as significantly reduce the risk of medical errors.

Accurately maintain records:

In order to avoid omissions and discrepancies, it is important for care settings to implement effective and efficient documentation practices. This includes ensuring that staff members are properly trained in how to use the system, promoting effective communication between staff members, and avoiding distractions such as personal cell phones when documenting patient information. A useful way of ensuring accurate record-keeping is by having all care providers sign off on each record they complete, verifying that it is accurate and complete.

Legible maintain records:

Care settings should ensure that each record they create is legible and easy to read, which will help care providers maintain accurate records and reduce the risk of medical errors. This includes recording information in an appropriate section or format for the type of information being documented, such as using specific fields for laboratory results. In addition, providing care providers with a variety of pens and types of paper can help ensure that records are legible.

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