Legal issues in record-keeping

It makes sense to start our look at record-keeping by looking at some of the legal issues around it.

Health departments in the UK make two things clear about the legal aspects of record-keeping in health services:

  • individuals who work for health care organisations are responsible for what they write
  • anything an individual writes in relation to their work as a health care employee becomes a public record.

Clearly, therefore, you must take care about what you write. Not only will you be asked to formally explain your records in the event of, for instance, a complaint from a patient/client, but patients/clients will be able to apply to see what you have written about them through the Data Protection Act.

Another key issue that arises is that of whether health care assistants are authorised to contribute to records about patients and record the care they give. Indeed they are, provided the registered nurse who delegates this responsibility is satisfied that the health care assistant is competent to undertake the activity and its documentation and that it is in the patient’s/client’s best interests for that record-keeping to be delegated. The registered nurse may choose to countersign the records created by the health care assistant until entirely confident about his or her competence in the complete activity, including record-keeping.

The RCN has produced guidance on delegating record-keeping and countersigning records.

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