Doctors are recommended to keep clear, accurate and legible records. Please refer to the GMC’s Good Medical Practice Handbook for full guidance.
Contemporaneous records at the time the events happen, or as soon as possible afterwards is advisable. Record any concerns, including any minor concerns, and the details of any action you have taken, information you have shared and decisions you have made relating to those concerns. Please make sure information that may be relevant to keeping a child or young person safe, is available to other clinicians providing care to them. Records containing personal information must be kept securely, in line with Data Protection Legislation.
Electronic health/medical records (EHR/EMR) are standard practice; currently CRS is used at KHFT. Proficient typing skills will be very helpful. It is highly likely that there will be Specialty Specific Templates that you will be briefed and encouraged to use, in the respective departments. If none exist, you might find SBAR (Situation, Background, Assessment and Recommendation) a useful documentation framework.
Proper use of our Electronic Records System (Currently CRS) will be explained / demonstrated at your Induction with our trust.
Please ensure that patient confidentiality rules are followed with all documentation and in your clinical practice. The law allows personal data to be shared between those offering care directly to patients, but it protects patients’ confidentiality when data about them are used for other purposes. When we use data for secondary purposes e.g. Audit/QIP or Research, we must only use data that do not identify individual patients unless we have the consent of the patient themselves.
Please visit NHS England’s Information Governance page for more detail.
You can also complete the e-learning for healthcare module on Data Security Awareness.
