News and presentations from today's Effective Records Management conference chaired by Mr Mike O’Connell, Legal Services Practitioner and Interim Senior Inquests Manager, Calderdale and Huddersfield NHS Foundation Trust.
Better Records for Patient Care
• better records for patient care: standards explained
• ensuring frontline staff are aware and are meeting the standards
• standardising care planning
• issues around diagnosis recording
Speakers:
Annette Gilmore Nurse, Researcher & Clinical Informatician, Professional Records Standards Body
Rebecca Hughes Director of Partner Solutions, Professional Records Standards Body
www.theprsb.org Becky started the presentation by explaining that the PRSB standards outline what information should be collected and recorded. She said it's important to engage frontline staff from the start and involve them in implementation of the standards using best practice outlined in the PRSB toolkit. Becky said it is a regulatory requirement to ensure certain information standards are implemented. The new Data Bill will widen the enforcement on IT system providers.
Annette followed Becky's talk sharing her experience on the frontline as a nurse by background and how they have developed their standards and share care records. She said consistency and accuracy of data collected is really important. It is important to understand what information should be collected and how it should be collected. The standards help with this, for example the Personal Care and Support Plan standard sets out what information should be included in a care plan for those with long-term conditions or complex needs.
Records Management: Legal Requirements and Advice
• importance and essential elements of documentation
• legal, professional, organisational & individual responsibilities when managing records
• handwritten clinical notes, emails, care plans and observation charts
• documentation challenges under paper and electronic systems
Speaker:
Hannah Bignell Secondary Care Liaison Manager, Medical Defence Union
Hannah gave an overview of good record keeping including its importance, what is required, GMC obligations and how to complete records to a high quality to avoid litigation or criticism. She also looked at a variety of scenarios covering different medico-legal considerations.
