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

The policies and guidelines that govern your records and documentation must meet specific requirements to guarantee that your records and documentation are legal, are fit for purpose, and meet your duty of care and other duties. To put it simply, it implies that any records you are working on should be up to date, comprehensive, accurate, and readable.

On-time and up to date records

An established practice is to keep records up-to-date. Individuals may want or require new or additional documentation, such as care plans, from time to time. It is important to routinely evaluate the documentation to see if it keeps up with their current requirements, wants, and preferences. Because of older paperwork, one of your employees may be obliged to undertake duties that are no longer essential and maybe even hazardous to a workforce member (e.g., administering a medication that is no longer needed). To prevent alterations to records, you should make handwritten alterations and then date and sign the alterations. An audit trail should be preserved for the record to help you retain the history of the document. Keep in mind that vital information, such as an individual’s address and contact information for their next of kin or personal physician, might change periodically, so make sure they are always up-to-date.

Completed records

It is necessary to guarantee that all relevant information is accounted for to prevent missing any data. The extra details you offer should be the best possible representation of the fact you are on the record and are stating facts. Since incomplete records might lead to personnel not knowing the entire picture or relying on guessing, this should be avoided. Regularly scheduling and adhering to a standard procedure to document projects can help to guarantee no tasks are overlooked.

Correct, current, up-to-date data

There is no alternative except to ensure that all records are completely accurate. Remaining true to the facts and writing in an impartial way means not mixing facts with personal feelings. It is not proper to mention your thoughts or thoughts while you are writing. If data are inaccurate, this might result in erroneous inferences being formed and a patient receiving improper treatment and assistance. In order to make sure you have all the necessary information; it is crucial to collect it as promptly as possible. Doing so helps maintain the most recent information and so helps with accuracy.

Clear and legible records

The records must be easily readable for readers to grasp and interpret the information contained inside. You may have to slow down you’re writing or even write in block capitals to ensure that your message is clear. For your work to be of use, you must ensure that others can’t read your records. Errors should be removed by striking through each undesirable word with a single line using an ink-remover or correction fluid; never use correction fluid or ink-remover.

This is an example.

Develop a set of guidelines to remind social care professionals of acceptable best practices in handling confidential information. In the instructions, you must comply. Provide instruction on proper record keeping, making sure the records are up to date, comprehensive, accurate, and readable. Describe ways to make sure that records are safely stored. To prevent security breaches, keep an eye on the task and follow the procedure step-by-step. Storage security features include distinct storage systems having particular features that help to guarantee security. Our Best Practice for Handling Information is to provide Adult Care Workers with Guidelines.

These recommendations are developed for care professionals who are in their adult years and are intended to present advanced approaches to handling information, such as record management, storage, and security.

Maintaining the record

The general expectation is that all documents be written neatly and legibly in black ink and be clear, brief, factual, and accurate. Any mistakes should be indicated to indicate that it is an error and has a line through it and signed. All required paperwork should be completed. To guarantee that every record is intelligible to everyone reading it and including all the relevant facts, it is important to implement this change. It is better to complete the project as soon as it is practical to do so since it will make you remember it more and remain current. The tasks should be done in privacy, and there should be no chance of being seen by unauthorised persons. Transparency and accountability are both important for maintaining good records. Include your signature, as well as the time, date, and your written name, on all documents to increase responsibility.

Recording storage

Legislation, corporate regulations, and best practices should all be followed when it comes to storing records. This indicates that they must be stored in a secure location that cannot be accessed by anybody who is not authorised. In the event of a fire, it may imply to escape from a locked room or a closed drawer. The organisation should not remove any records from the workplace unless it is absolutely necessary, and all such records should be returned to a safe location as soon as they have been changed.With the strict permissions requirements, passwords and safeguards in place, electronic records should be secured to only allow authorised users to view them. Record retention should be just for as long as needed and disposed of in an environmentally conscious manner (e.g., shredded).

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