![]() Take immediate action when inaccurate information is discovered You can learn more about how we can help on our medical document scanning services page.Ħ. One way you can start building an electronic management system is by scanning physical documents to a secure online portal. This is because it is easier to audit access to digital records, they are quicker to file and retrieve and they take up much less storage space than physical records. Move to digital storageĪs stated by the NHS Records Management Code of Practice 2021, medical organisations should be moving towards digital records. ![]() When taking an audio or visual recording, it’s essential to be completely transparent with patients about how the record will be used and what happens to the recording following the interaction (i.e. Treat audio and visual recordings the same wayĪn audio or visual recording should be treated in the same way as a textual record, meaning it must be safely stored for the entirety of its retention period. This good record keeping practice ensures that future clinicians have a complete picture of the information on which a patient’s treatment was based at any point in time. When making an alteration, any rectified information should still be legible by running a single line through it, rather than completely deleting the entry. ![]() Sign and date further additions or alterationsĪny further additions or alterations to a record must be signed and dated. To ensure they are as accurate as possible, records should be made during the consultation or soon after, and dated. Make sure records are clear, accurate and legibleĪccording to the GMC, those creating a medical record have a professional obligation to record them in line with the Data Protection Act 2018 - meaning they should be accurate, clear and legible. Any drugs prescribed or other investigation or treatmentĢ.The decisions made and the actions agreed, and who is making the decisions and agreeing the actions.In their ethical guidance, the General Medical Council lists several key pieces of information which must be included within a clinical report. One of the most important principles of good record keeping is to take comprehensive notes in the first place. ![]() When creating a medical record in any of the above formats, whether that’s physically or remotely, it’s essential that you follow good practice in record keeping to ensure the best patient care and provide evidence in case of a claim.ġ0 record keeping tips for medical records 1. Text or email communication with patients.Images, x-rays, photographs, videos and other recordings.Registers, including birth, death, theatre, Accident and Emergency, etc.Correspondence between health professionals.There are a number of different types of material that can be considered a medical record. A medical record is any form of document you create to formally record your work. ![]()
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