Electronic Health Records Policy (Including Record

The general principle is that all correspondence which helps to improve a patients understanding of their health and care should be copied to them as a right. [...] The record may also bePage 13 of 37 accessed by other professionals for the purposes of health and care delivery and they must be able to understand what it written. [...] Where a health professional wishes to abbreviate anything, this should be written in full in the first instance with the abbreviation written in brackets. • Factually accurate and relevant – Healthcare records must be a factual record of care that is delivered and where possible, collateral evidence should be sought. [...] The purpose of a healthcare record is to facilitate the care, treatment and support of a patient. [...] More specifically maintaining the security and confidentiality of information is vital for clinical records to protect patient confidentiality. [...] In brief, it is important that during this process: • All documents are scanned to a standard that they will be able to be opened and read on the EPR system. [...] This is unlikely to be a problem provided it can be demonstrated that the scan is an authentic record and there are technical and organisational means to ensure the scanned records maintain their integrity, authenticity and usability as records, for the duration of the relevant retention period. [...] If the person is a young carer, any information must be appropriate to age and understanding of the young person. [...] 11.4.3 Witness Protection Health Records Where a record is that of someone known to be under a witness protection scheme, the record must be subject to greater scrutiny and confidentiality. [...] Digital media that needs to be retained specific to a patient should be labelled as with any other record and where practical included in the patient’s clinical record.