Information governance and record keeping in community practice

Community Pract. 2014 Feb;87(2):43-6; quiz 46.

Abstract

The quality of NHS record keeping and documentation has been a cause for concern in recent serious case reviews and inquiries. It is also a source of health professional referral to fitness to practise panels. Community practitioner record keeping is governed by national legislation as well as local policy. Recent developments in record keeping practice, not least the progressive move to electronic records, mean that legislation and policy must be reinterpreted to take account of new challenges and dilemmas. As community practitioners frequently work collaboratively with colleagues from other professions and organisations, efforts must be made to develop a shared understanding of the content and handling of records containing personal confidential information.

MeSH terms

  • Community Health Services / legislation & jurisprudence*
  • Community Health Services / organization & administration*
  • Confidentiality / legislation & jurisprudence*
  • Confidentiality / standards*
  • Electronic Health Records / legislation & jurisprudence*
  • Electronic Health Records / standards*
  • Humans
  • State Medicine / legislation & jurisprudence*
  • United Kingdom