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Why is record keeping important in care homes?

Fonthill House, St Albans, Hertfordshire

If you’re involved in the running of a care home or other care services, you’ll understand the importance of keeping accurate records. It’s not just about ticking legal boxes either, it’s vital to provide the best possible care for your residents. Let’s explore the importance of record keeping in care homes and how to maintain these crucial records.

What are healthcare records?

The 2018 Data Protection Act describes a health record as: “personal data relating to the physical or mental health of an individual, including the provision of health care services, which reveals information about his or her health status”.

Data for healthcare records can be recorded in a variety of ways from digitally to handwritten notes. These records need to be kept up-to-date as well as being dated and signed, including any discussions with the resident so any feedback is taken on board. When patients are receiving specialist care, these records are vital. 

Essentially, healthcare records contain information about the resident, the care they receive and any medications/treatments they are having. This is why it’s no surprise that these records are extremely important, as they contain everything a carer needs to know about a patient.

Why is record keeping in care homes important?

Keeping records should never be seen as an administrative burden in care homes. They are integral in providing person-centred care that supports each and every individual resident fully. Here are some of the key ways that record keeping is essential in care homes:

  • Full history – having complete and accurate medical records tells all caregivers the full story of a patient’s medical journey
  • Seamless care – medical records allow one caregiver to pick up where another left off with a full understanding of the patient
  • Identify areas of improvement – accurate medical records can highlight any patient feedback or areas of weakness in care
  • Promotes patient health – digital charts are a great way to monitor the health of a patient and see improvements, this focus on medical history encourages changes to be made
  • Legal requirement – keeping up-to-date medical records is part of a care home’s professional duty 
  • Accountability – by having to regularly fill in records, staff are held accountable for all care, giving residents peace of mind 
  • CQC compliance – the Care Quality Commission states that care homes should be safe, effective, caring, responsive and well-led. Having accurate healthcare records helps to meet these standards

What could happen if records are poorly kept?

If medical records aren’t kept up-to-date and staff don’t take the time to fill them out accurately, then countless things can go wrong, endangering both residents and the reputation of your care home:

  • Endanger residents – if all carers aren’t aware of a resident’s full medical history, then they could endanger them by administering incorrect medications or being unaware of allergies etc.
  • Lower standards of care – by poorly recording medical histories, your care home doesn’t have any way to make improvements to your care, this means your overall standard of care will be low
  • Miscommunication – this is one of the greatest risks of poor medical records. As different carers look after the same resident, you won’t be able to provide seamless care and this miscommunication can be dangerous
  • Lack of compliance – not only is it illegal but you won’t be compliant with the CQC standards of care and you can’t provide evidence if you were ever taken to court
  • Poor reputation – by not maintaining accurate medical records, your care home will quickly attain a poor reputation for care as residents won’t receive the quality care they deserve

How to maintain records in care homes

Now you know just how important accurate healthcare records are. There are some fundamental principles that must be followed to deliver the best care whilst maintaining up-to-date records:

Don’t miss key details

Even minor details can make all the difference when it comes to keeping medical records. It’s important to note down anything of interest or that strikes you as unusual, whether it’s the patient’s mood or how they react to certain actions. Also, make sure you write down what medicine was administered and when, these details are absolutely essential to medical records.

Make sure records are clear and accurate

Medical records need to be succinct and 100% accurate, there shouldn’t be any room for misinterpretation when the next carer reads your notes. Avoid using complicated phrases or overwriting and describing things in too much detail, just stick to the facts and leave any opinions out of the record. If you do have a concern or opinion, this can be added to the record as long as facts are used to back it up. Also, don’t guess times or doses, these need to be recorded accurately.

Sign and date further additions or alterations

It’s important to sign every medical record as then other carers can come to you if they have any questions. Adding a date is also key as then the development of a patient’s health can be tracked over time. If treatment or care changes, these alterations must be recorded with a date and name, this is essential to avoid miscommunication and to successfully provide seamless care. 

The importance of keeping accurate medical records in care homes can’t be overstated. These records are the key to providing person-centred care that improves the health of your patients. Not to mention that it makes everyone’s job much easier!

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