Record keeping audit 2012 – round 1

The aim of this  national audit was to assess variations in practice with respect to clinical record keeping in OH departments that serve NHS trusts in England. It enabled OH departments to compare the quality of their OH record keeping with national standards and other services providing to the NHS.

The audit subsequently formed part of the National Quality Improvement Programme (NQIP) and was available to all OH services in the UK from August 2013.

Key recommendations

  • OH departments should invest in suitable electronic record systems that:
    • are secure (prevent alterations or deletions, or allow alterations only by restricted authority and with a clear audit trail to track any changes retrospectively)
    • comply with NHS information governance standards.
  • Pending the introduction of electronic systems, OH departments with paper-based record systems should:
    • investigate simple changes that will increase compliance for recording the patient’s name and date of consultation on each side of paper and the author’s name and designation at least once on the record.
  • Regardless of whether records are paper or electronic, clinicians should:
    • record consent under the Access to Medical Reports Act before they request a report from another clinician
    • document carefully that copies of any reports to managers have been offered to the patient.

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