Summary
Summary 4.3 explain how to maintain records
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Explain how to maintain good records and why it is important to do so. and suggest measures that can be implemented to promote good documentation keeping
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Amina AnwarUnit 4 Communication in Health and Social Care
C3 – Explain how to maintain records
Learner number - 104888422
Submission date – 15th October
A record is information about an individual relating to their health. It has all the necessary
information that other staff will need if they need to understand more about a patient.
It is important to keep records in order to understand more about the patient. The record might
have any medication they take, allergies they have, and any medical conditions or disorders.
You can maintain good records by updating records and do not write any false information in the
record as this could cause harm to patients. This helps to maintain good records because any new
information that you write is useful. This is because they will know what actions you have done such
as medication to help the patient. This helps communication in HSC settings because you are writing
anything that is useful in the record.
Any decisions that you have made towards the patient should be provided with evidence. This helps
to maintain records as you have made decisions and actions so there must be a reason or evidence
provided to why you did this.
Records should be factual and clear to ensure that no mistakes are made when others staff are
reading patient’s record. This helps to maintain records because it would be easier for staff to read
the records if everything is factual and easy to understand. This aids communication in health and
social care settings because everything that is written in the record would be unambiguous and clear
to make it easier for the reader.
Anything you write about a patient should have evidence or an explanation to support why you
wrote it. This helps to maintain records because it shows the reader that they have used valid
evidence in order to support their decision of what is written in the record. This aids communication
in H&S settings because staff will rely on the information to treat a patient.
Make sure that anything you write has a date and time and has been signed with your name. You
must ensure that you write your initials so your name does not get misunderstood with another.
This helps maintain records because it shows the reader when the record is written and who it was
written by. This aids communication because it shows who it was written by and when. This makes it
easier for staff because if they are reading a patient record they know who it was written by.
Make sure that anything you write should not be seen by others. Staff should be cautious for
unauthorised access to any medical records. This is because a patient record should not be seen by
others who have unauthorised access. This helps maintain records because records are confidential
which means that only staff are allowed to see them. This aids communication because anything
written in the records will be written by staff. They will be able to understand if anything is not
written by a member of staff.
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