OUR DUTY
As health care professionals we all have a duty to ensure patient care is documented correctly. Patient records are fundamental to health care practice and form a permanent account of the patient’s illness and care received.
When documenting clinical information, we as health care professionals are recording information for future reference.
If you did not write it down, it did not happen
If it is not recorded, it has not been done, has not been considered, or was not said
Lynch J (2009)
WHAT DOES THE DATA PROTECTION ACT 1998 STATE?
The DATA PROTECTION ACT (1998) states that legal data should be:
- Fairly and lawfully processed
- Processed for limited purposes
- Adequate, relevant and not excessive
- Accurate
- Not kept for longer than is necessary
- Processed in line with subjects' rights
- Secure
"All residents, subject to certain conditions, have a right to access their own records in an intelligible form, as well as the right to have investigative hearings whereby medical records will be considered as evidence"
(UK Government, 1998)