Active’s Record Keeping Policy
Active’s records relating to the care and treatment of each person using the service must be kept and be fit for purpose. Fit for purpose means that records must:
- Be complete, legible, indelible, accurate and up to date, with no undue delays in adding and filing information, as far as is reasonable. This includes results of diagnostic tests, correspondence and changes to care plans following medical advice.
- Include an accurate record of all decisions taken in relation to care and treatment and make reference to discussions with people who use the service, their carers and those lawfully acting on their behalf. This includes consent records and advance decisions to refuse treatment. Consent records include when consent changes, why the person changed consent and alternatives offered.
- Where appropriate, indicate how you have offered Clients choices, no matter how small and support to enable them to make informed decisions. Detail any special communication systems used, such as objects of reference, Makaton etc. Detail what Clients have done for themselves and the level of support provided (i.e. prompt, guide or observe Clients doing task independently).
- Be accessible to authorised people as necessary in order to deliver people’s care and treatment in a way that meets their needs and keeps them safe. This applies both internally and externally to other organisations.
- Be created, amended, stored and destroyed in line with current legislation and nationally recognised guidance.
- Be kept secure at all times and only accessed, amended, or securely destroyed by authorised people.
- Both paper and electronic records can be held securely providing they meet the requirements of the Data Protection Act 1998.
- Decisions made on behalf of a person who lacks capacity must be recorded and provide evidence that these have been taken in line with the requirements of the Mental Capacity Act 2005 or, where relevant, the Mental H
Use to answer question 14.1a of the Care Certificate
ealth Act 1983, and their associated Codes of Practice.