FSRH Service Standards for Record Keeping - July 2019

Published on: 8 July 2019

File size: 1223kb PDF

File type: Clinical Standards

Contemporaneous and high quality record keeping is an important aspect of clinical risk management. It ensures that clinicians and other staff have timely access to information relevant to the patient’s current episode of care. It facilitates clear communication to other involved clinicians justifying decision-making for actions taken. In the event of complaints, untoward incidents and medico-legal cases, accurate and comprehensive documentation supports prompt resolution. In addition, good clinical records support audit, management, planning, policy, commissioning and research.
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