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Accurate record keeping is more than just good admin – it’s good manners

Posted by: , Posted on: - Categories: Information and access

No one appreciates having to repeat their medical history or care needs, especially when they find the information wasn’t accurately recorded the first time! As social workers, clinicians and care workers, we cannot allow these lapses to happen when individuals share deeply personal details with us. It’s not just bad record keeping – it's disrespectful and potentially harmful.

We need something our health and social care services currently lack - a joined-up, coherent health and social care record system

Such omissions heap anxieties upon anxieties - for service users, providers and carers, who might rightly wonder if anyone has a proper handle on a person’s needs and concerns.

A grip on the detail is essential, particularly when health and care decisions must be made quickly to mitigate or prevent a crisis. So, what’s the solution?

We need something our health and social care services currently lack - a joined-up, coherent health and social care record system.

And that requires the introduction of care record standards to reduce variation in quality and content, whilst simultaneously enabling that content to be shared across different IT systems and care settings without losing their meaning and usefulness.

Lorraine Foley: 'Standardised records will give us timely access to crucial clinical information about the people we’re trying to help.'

Recently, I met with Lorraine Foley, CEO of the Professional Record Standards Body (PRSB), an independent membership organisation representing some 750,000 health and social care professionals including ADASS, ADCS and the independent care sector - as well as patient groups such as National Voices.

The PRSB is helping to improve patient care by creating standards for digital health and care records and promoting their use with health and social care professionals to support greater service integration.

“Currently, there’s a lot of variation in the content and quality of care records being shared between health services and care professionals,” Lorraine explained to me, “which can lead to inconsistency and gaps in information. Standardised records will give us timely access to crucial clinical information about the people we’re trying to help.

“That way we can assess their needs better and arrange the support they require to manage long term conditions, mobility issues or recovery from mental ill health while living as independently as possible.”

To this end, the PRSB has published a series of record standards which, once fully implemented, I am sure will enhance health and social care service delivery across the board.

Recent standards include:

  • the electronic discharge summary, which sets out the information that needs to be sent digitally following a hospital discharge;
  • the mental health discharge summary standard, which sets out the information that needs to be sent from mental health services to primary care to ensure continuity of care;
  • and a crisis care standard, which enables health and care professionals to access relevant information following treatment and update a person’s changing care requirements such as end of life care plans and Do Not Resuscitate (DNR) orders.

NHS Digital has also published the flow of information between hospitals and local authorities.

A number of national social care messages have also been produced to make it easier to share information between different IT systems.

They’re now working on a new standard in care planning, to ensure all relevant information on a person’s long-term care plans can be shared with multi-disciplinary teams across different care settings.

The PRSB is also working with NHS England and NHS Digital to develop standards for self-care to support personalisation. It’s important that our social work and broad social care expertise - in the context of citizen involvement – is reflected in this as well.

They’re looking for our involvement in this project on an ongoing basis. They will be holding a series of workshops and surveys over the coming months, to find out what information would be most useful to care providers. To find out more about how you can help with this and other projects, visit their website, contact them by email, or call them on 020 7922 7976.

The work they are doing is so important and I wholeheartedly endorse it. More than that, I would like to see our profession championing the adoption of these standards across the whole range of health and social care services. I encourage you all to get involved in planning how to embed these standards locally and regionally.

To care is to share – let’s put it on record!

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  1. Comment by Mark Holloway posted on

    Thank you Lyn, I wholeheartedly agree regarding making people constantly re-state their story and the unnecessary damage this does.

    A friend of mine has a profoundly learning disabled son, he is approaching 18 and plans are needing to be made for his longer-term. Firstly my friend has never seen the same social worker twice, no trusting relationship has been enabled to develop therefore and secondly she informs me that no new social worker appears to have read the file. Whilst I may (as a social worker) understand that the new member of staff may wish to hear the whole story first-hand, my friend reports that it comes across to her as though no one has bothered to take the time to read his records. This is reinforced by the fact that staff regularly ask very basic questions that, had they read the file, they would know the answer too.

    Any plans that support staff to learn more and prevent needless repetition of what are often very emotionally taxing stories to tell will be a valuable thing. I would however say that continuity of staffing would of course be an even greater contribution to this issue. As someone who has had the privilege to work alongside some families affected by severe brain injury for over 17 years, I am aware that the relationships that can develop over time are ones that can be very beneficial to client and family and aid learning by staff.

  2. Comment by Susan posted on

    We must make sure that the case notes are written up as accurately as possible, as the policy of slapdash writing has been very detrimental to our clients and patients.

  3. Comment by A. Watson posted on

    "We need something our health and social care services currently lack - a joined-up, coherent health and social care record system"

    This has been on the health and social care agenda for the last 12 years - yet nothing seems to change. No integrated I/T systems, increasing barriers to the sharing of information, people still telling their "history" multiple times .... what is the government doing about it ?

  4. Comment by j posted on

    That is one of the points~ no or very little joined up thinking! If only All the computers in All GP surgeries and Hospitals talked to each other, a huge amount of cash would be saved.
    I have been given the run- around, wasted precious time both of myself and consultants many times, all because computers in different hospitals were not linked. This is duplicated all over the UK every day. Get it sorted, please.


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