Essence of Care

2010

Benchmarks for Record Keeping

Document Purpose ROCR Ref: Title Author Publication Date Target Audience

Best Practice Guidance 0 Gateway Ref: 14641 0

ESSENCE OF CARE 2010 DEPARTMENT OF HEALTH 1ST OCTOBER 2010 PCT CEs, NHS Trust CEs, Care Trust CEs, Foundation Trust CEs , Directors of Nursing, Local Authority CEs, Directors of Adult SSs, PCT PEC Chairs, Special HA CEs, Allied Health Professionals, GPs, Communications Leads, Emergency Care Leads, Directors of Children's SSs, Universities UK, RCN, RCM, AHPF, SHA Lead Nurses, SHA AHP Leads, Patient Organisations

Circulation List

PCT CEs, NHS Trust CEs, Care Trust CEs, Foundation Trust CEs , Directors of Nursing, Local Authority CEs, Directors of Adult SSs, PCT PEC Chairs, Special HA CEs, Allied Health Professionals, GPs, Communications Leads, Emergency Care Leads, Directors of Children's SSs, Voluntary Organisations/NDPBs, Universities UK, RCN, RCM, AHPF, SHA Lead Nurses, SHA AHP Leads, Patient Organisations

Description

Essence of Care 2010 includes all the benchmarks developed since it was first launched in 2001, including the latest on the Prevention and Management of Pain. All the benchmarks have been reviewed to reflect the current views of people requiring care, carers and staff

Cross Ref Superseded Docs Action Required Timing Contact Details

Essence of Care 2001, Communication, Promoting Health and Care Environment Essence of Care 2001 Gateway No. 4656 and 8489 0 N/A 0 N/A Gerry Bolger CNO Directorarte - PLT 5E58, Quarry House Quarry Hill, Leeds LS2 7UE 01132546056 www.dh.gov.uk 0

For Recipient's Use

Essence of Care 2010 Benchmarks for Record Keeping

Essence of Care 2010
Benchmarks for the fundamental aspects of care

Benchmarks for Record Keeping

Essence of Care 2010 Benchmarks for Record Keeping

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Published with the permission of the Department of Health on behalf of the Controller of Her Majesty’s Stationery Office. © Crown Copyright 2010 All rights reserved. Copyright in the typographical arrangement and design is vested in the Crown. Applications for reproduction should be made in writing to the Office of Public Sector Information, Information Policy Team, Kew, Richmond, Surrey, TW9 4DU. First published 2010 ISBN 978 0 11 322881 2 Printed in the United Kingdom for The Stationery Office. J002352911 cXX 09/10

Contents
Best Practice – General Indicators
Factor 1

4 9 10 12 13

Access to care records
Factor 2

Single records
Factor 3

Practice and evidence
Factor 4

Security

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Essence of Care 2010 Benchmarks for Record Keeping

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Best Practice – General Indicators
The factors and indicators for each set of benchmarks focus on the specific needs, wants and preferences of people and carers. However, there are a number of general issues1 that must be considered with every factor. These are:

People’s experience
■■ People feel that care is delivered at all times with compassion and

empathy in a respectful and non-judgemental way ■■ The best interests of people are maintained throughout the assessment, planning, implementation, evaluation and revision of care and development of services ■■ A system for continuous improvement of quality of care is in place

Diversity and individual needs
■■ Ethnicity, religion, belief, culture, language, age, gender, physical,

sensory, sexual orientation, developmental, mental health, social and environmental needs are taken into account when diagnosing a health or social condition, assessing, planning, implementing, evaluating and revising care and providing equality of access to services

Effectiveness
■■ The effectiveness of practice and care is continuously monitored and

improved as appropriate ■■ Practice and care are evidence-based, underpinned by research and supported by practice development

Consent and confidentiality
■■ Explicit or expressed valid consent is obtained and recorded prior to

sharing information or providing treatment or care

1

Also see Department of Health (2010) NHS Constitution The NHS belongs to us all. Department of Health: London accessed 07 May 2010 at http://www.dh.gov.uk/prod_consum_dh/groups/ dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113645.pdf

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Essence of Care 2010 Benchmarks for Record Keeping

■■ People’s best interests are maintained where they lack the capacity to

make particular decisions.2 ■■ Confidentiality is maintained by all staff members

People, carer and community members’ participation
■■ People, carers’ and community members’ views and choices underpin

the development, planning implementation, evaluation and revision of personalised care and services and their input is acted upon ■■ Strategies are used to involve people and carers from isolated or hard to reach communities

Leadership
■■ Effective leadership is in place throughout the organisation

Education and training
■■ Staff are competent to assess, plan, implement, evaluate and revise care

according to all people’s and carers’ individual needs ■■ Education and training are available and accessed to develop the required competencies of all those delivering care ■■ People and carers are provided with the knowledge, skills and support to best manage care

Documentation
■■ Care records are clear, maintained according to relevant guidance and

subject to appropriate scrutiny ■■ Evidence-based policies, procedures, protocols and guidelines for care are up-to-date, clear and utilised

Service delivery
■■ Co-ordinated, consistent and accessible services exist between health

and social care organisations that work in partnership with other relevant agencies

2

Mental Capacity Act 2005 accessed 25 November 2008 at http://www.legislation.gov.uk/ ukpga/2005/9/contents

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Essence of Care 2010 Benchmarks for Record Keeping

■■ Care is integrated with clear and effective communication between

organisations, agencies, staff, people and carers ■■ Resources required to deliver care are available

Safety
■■ Safety and security of people, carers and staff is maintained at all times

Safeguarding
■■ Robust, integrated systems are in place to identify and respond to

abuse, harm and neglect3 ■■ All agencies working with babies, children and young people and their families take all reasonable measures to ensure that the risks of harm to babies, children’s and young people’s welfare are minimised.4

3

Department of Health (2010) Clinical Governance and Adult Safeguarding – An Integrated Approach Department of Health: London accessed 30 May 2010 at http://www.dh.gov.uk/prod_consum_dh/ groups/dh.digitalassets/@dh/@en/@ps/documents/digitalasset/dh_112341.pdf Department of Health (2006) Safeguarding Children. A Summary of the Joint Chief Inspector’s Report on Arrangements to Safeguard Children Department of Health: London accessed 30 May 2010 at http//www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/ DH_4103428

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Essence of Care 2010 Benchmarks for Record Keeping

Benchmarks for Record Keeping
Agreed person-focused outcome people benefit from records that promote communication and high quality care

Definitions
For the purpose of these benchmarks, a care record is: any paper or electronic-based record which contains information or personal data pertaining to people’s care. For simplicity, people requiring care is shortened to people (in italics) or omitted from most of the body of the text. People includes babies, children, young people under the age of 18 years and adults. Carers (for example, members of families and friends) are included as appropriate. The term carers refers to those who ‘look after family, partners or friends in need of help because they are ill, frail or have a disability. The care they provide is unpaid’. (adapted from Carers UK, 2008). Please note, within these benchmarks it is acknowledged that the term ‘carer’ can include children and young people aged under 18 years. The term staff refers to any employee, or paid and unpaid worker (for example, a volunteer), who has an agreement to work in that setting and is involved in promoting well-being. The care environment is defined as an area where care takes place. For example, this could be a building or a vehicle. The personal environment is defined as the immediate area in which a person receives care. For example, this can be in a person’s home, a consulting room, hospital bed space, prison, or any treatment/clinic area.

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Essence of Care 2010 Benchmarks for Record Keeping

Agreed person-focused outcome people benefit from records that promote communication and high quality care Factor
1. Access to care records 2. Single records

Best practice
People are able to access their care records in a format that meets their needs People have a single, lifelong, multi-professional and multi-agency (where appropriate) care record which supports integrated care People’s care records demonstrate that their care is evidence-based People’s care records are safeguarded

3. Practice and evidence 4. Security

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Essence of Care 2010 Benchmarks for Record Keeping

Access to care records
Please note that this benchmark must be used in conjunction with the How to use Essence of Care 2010 document

Factor 1

Poor Practice people are unable to access their care records

Best Practice

 

people are able to access their care records in a format that meets their needs

Indicators of best practice for factor 1
The following indicators underpin best practice: a. general indicators (see page 4) are considered in relation to this factor b. people have access to their care records c. people’s and the public’s awareness of accessibility of care records is promoted d. people are aware that there are circumstances in which part of their care record may not be accessible, for example, if a professional considers it likely to cause serious harm to people or others e. people have a copy of their care plan (where appropriate) f. information about care records is provided in a format that is accessible to people

g. systems are in place for the efficient retrieval of care records h. add your local indicators here
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Essence of Care 2010 Benchmarks for Record Keeping

Single records
Please note that this benchmark must be used in conjunction with the How to use Essence of Care 2010 document

Factor 2

Poor Practice people have multiple records held by a variety of professions and agencies

Best Practice

 

People have a single, lifelong, multi-professional and multiagency (where appropriate) care record which supports integrated care

Indicators of best practice for factor 2
The following indicators underpin best practice: a. general indicators (see page 4) are considered in relation to this factor b. a single electronic care record is utilised amongst all relevant staff and services (where possible and appropriate) to provide consistency and continuity of care c. care records that are held by people are user friendly and meet any special needs d. staff discuss and agree with people what they are going to write in the care records e. care records are comprehensive, accurate, clear and free from unauthorised abbreviation

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Essence of Care 2010 Benchmarks for Record Keeping

f.

care records are audited against regulatory and professional standards, and local and national guidance5 for record keeping, such as the NHS Care Records Guarantee,6 Records Management Code of Practice,7 and Information Governance guidance8

g. staff are competent to create, use and maintain care records, including the ability to keep accurate, comprehensive, care records h. care records are shared by staff according to Caldicott principles9 and information sharing protocols i. add your local indicators here

5 6 7

DH (2007) Social Care Information Governance accessed 28 November 2008 at http://www. dh.gov.uk/en/Managingyourorganisation/Informationpolicy/Informationforsocialcare/DH_4075306 Department of Health (2009) The Care Record Guarantee. Our Guarantee for NHS Care Records in England accessed 25 July 2010 at http://www.nigb.nhs.uk/guarantee/2009-nhs-crg.pdf Department of Health (2006) The Records Management: NHS Code of Practice accessed 28 November 2008 at http://www.dh.gov.uk/en/Managingyourorganisation/Informationpolicy/ Recordsmanagement/index.htm Department of Health (2007) NHS Information Governance – Guidance on Legal and Professional Obligations accessed 28 November 2008 at http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_079616 Department of Health (1997) Report on the Review of Patient-Identifiable Information accessed 25 July 2010 at http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@ en/documents/digitalasset/dh_4068404.pdf

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9

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Essence of Care 2010 Benchmarks for Record Keeping

Practice and evidence
Please note that this benchmark must be used in conjunction with the How to use Essence of Care 2010 document

Factor 3

Poor Practice people’s care records fail to demonstrate evidence based practice

Best Practice

 

people’s care records demonstrate that their care is evidence-based

Indicators of best practice for factor 3
The following indicators underpin best practice: a. general indicators (see page 4) are considered in relation to this factor b. people’s care records demonstrate that their care follows evidencebased guidance and any variance from this is explained c. recorded variance is analysed and used to inform changes in people’s care d. agreement is reached between staff on evidence-based documentation e. people’s involvement in the development of evidence-based documentation is facilitated and supported f. audits are undertaken of care records, the results are used to improve practice and care

g. review of quality and content of documentation is evident h. add your local indicators here
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Essence of Care 2010 Benchmarks for Record Keeping

Security

Factor 4
Please note that this benchmark must be used in conjunction with the How to use Essence of Care 2010 document

Poor Practice people’s care records are not safeguarded

Best Practice

 

people’s care records are safeguarded

Indicators of best practice for factor 4
The following indicators underpin best practice: a. general indicators (see page 4) are considered in relation to this factor b. people’s confidentiality is respected c. people are aware that there are circumstances in which confidential information about them may be used or disclosed, for example, reporting infectious diseases, births of children or where there is a court order d. people are aware of the choice they have to decide whether their information can be disclosed or used in particular ways e. people’s confidentiality is respected according to Caldicott principles f. arrangements are in place to send and receive confidential information in a secure setting, such as when sending faxes of information concerning care

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Essence of Care 2010 Benchmarks for Record Keeping

g. paper and electronic records can only by accessed by specified individuals using a secure system h. people’s care records on removable media (such as tapes, disks, laptop and handheld computers, optical discs (DVD and CD-ROM), solid state memory cards, memory sticks and pen drives) is encrypted to the appropriate standards i. care records and information concerning people are not left accessible or in public places, for example, there is a ‘clear desk’ policy in place that is adhered to and staff ‘log out’ of electronic record systems when not in use care records are stored and transported securely and there is a record tracking system in place

j.

k. there is a system to dispose of care records appropriately that includes their destruction l. add your local indicators here

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Notes

Notes

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