2.3 Maintain accurate, complete, retrievable, and up to date records

Course: NVQ Level 4 Diploma In Health And Social Care (RQF)

Unit 11: Develop, maintain and use records and reports

LO2: Be able to prepare professional records and reports that meet legal requirements, and agreed ways of working

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2.3 Maintain accurate, complete, retrievable, and up to date records

It is important that you keep your records and documentation up-to date, completely accurate as wella nd readable. This way there won’t be any issues with them being lawful or fit for purpose which can lead into more problems than good.

Accurate records

Records should always be accurate – this means any document you complete must have the correct information. Any errors may lead to incorrect decisions being made based upon the documents completed, if are unable to maintain your accuracy it could mean that there is no clear record being shown of what has actually taken place. This will then cause confusion over whether care was offered or received.

The level of accuracy must remain appropriate for each individual situation/record that is being created, used, and stored. If legal requirements are needed then these have to be met at all times where appropriate e.g. recording any accidents properly so they can be investigated fully by an external party without too much confusion or uncertainty.

Complete records

When creating documents to keep records of certain events you should try and make sure that everything is complete, this means recording every important fact. When completing documentation it may be difficult to think of everything at the time but information can be added later on providing there is no delay in doing so.

Sometimes there could be a situation where your records are not complete which will cause issues when trying to provide evidence in follow-up care or further investigations. If for example you only record the main areas of concern then this would not give much information if something happens in the future and you need to refer back to previous notes or reports that were completed when they needed support either at home or within an external environment such as a hospital. This may mean it becomes more difficult to identify what has actually taken place.

Records should remain relevant to the original purpose of why they are being used for. If they are not fulfilling this criterion then there may be instances when further information is required in order to provide better care.

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Retrievable records

Your records must be easy to find and retrieve when they are needed, otherwise, certain tasks or procedures would become more difficult than it needs to be for everyone involved. You cannot just rely on one person knowing where things are kept as you need to know that they will be available whenever needed, which can sometimes mean carrying them around constantly with you if your work involves traveling between different places that require them.

If you do lose your documents then don’t panic! There are ways to retrieve them and they should be available to you as soon as possible, this may involve contacting the agency that was keeping them safe on your behalf.

Up to date records

Records should always be up to date. Ensure that you have kept up to date with your paperwork/records. Any records should be updated as soon as they are needed. If you are unable to update the record upon request, ask for an extension if possible.

There will be situations when your records may not be complete, you should always try to take the appropriate steps in order to ensure that your records remain up to date. This will include cross-referencing with other individuals within the same service or by speaking with external agencies. These circumstances can vary from individual circumstances, varying between documents or even relating to different circumstances that may arise due to any change of carers. Just because a nurse reports that a patient has been prescribed medication does not mean they have received it, there could be a number of factors causing this situation meaning that their records may not stay current at all times.

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