OCCUPATIONAL THERAPIST
Royal College of Occupational Therapists guidance: https://www.rcot.co.uk/sites/default/files/Keeping%20records%20-%20guidance%20for%20occupational%20therapists%202017.pdf
When you consider the requirements of the HCPC and RCOT standards, there are key words that identify the necessary elements of quality which are required. Every service user with whom you have contact must have records that are:
- full/comprehensive;
- clear/comprehensible;
- accurate;
- promptly completed;
- demonstrating your clinical reasoning and evidence;
- compliant with legislation, guidance and policy on completion, confidentiality, sharing and service user access; and
- securely stored and suitably disposed of.