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.
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.
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:
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:
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:
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.
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.
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!