As a healthcare practitioner you are required to keep up to date, accurate and comprehensive patient’s records;
They must contain :
Also you should include:
- The patients full name, address, telephone number and date of birth
- the presenting complaints and symptoms reported by the patient
- your clinical findings and diagnosis
- the description of any treatment given and progress of the case, information about any herbal medicine given to the patient
- the records of the patient's consent to the treatment, or the consent of their next-of-kin or a legal guardian
- any information and advice given to the patient and the treatment planned
- any relevant medical and family history
- any known allergies, adverse or unusual reactions to the treatment
- any decisions made regarding the patient
You must also ensure that adequate records of adult treatments are kept for seven years, or as long as your insurer requires you to do so. In the case of minors their records must be kept until the patient reaches the age of twenty-five. This applies even when you have referred the patient on, or you have left the practice where you administered the treatment.
- to comply with the rules and regulations set in the Data Protection Act 1998 at all times in regards to storing, processing and destroying of your patient’s personal records;
- not to use information gained about your patient in any other way than is necessary for their treatment;
- not to use information gained about your patient for the purpose of your personal or professional benefit.
In the event of patient requesting access to their case records, you should produce a copy of the notes but retain the originals. If a UK citizen you must act in a way that observes the procedure laid out in the Data Protection Act 1998 www.legislation.gov.uk
. The Act is complex and a summary of it can be found online www.ico.org.uk
. Any UK members moving outside the European Economic Area need to be aware personal data must not be transferred to a country unless it has an adequate level of protection for the rights and freedoms of data subjects.
Non UK members must ensure they comply with the relevant data protection legislation in their country.