Inaccurate and inaccessible patient records
Failure to maintain easily accessible, up-to-date, and accurate information about patients/service users in care settings.
37 items
1 source
12 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
87match
F244 - Common information practices shared data and electronic records
There is a need for all to accept common information practices, and to feed performance information into shared databases for monitoring purposes. The following principles should be applied in considering the introduction of electronic patient information systems: Patients need to be granted user friendly, real time and retrospective access to read their records, and a facility to enter...
Matched on
terms: patient, record
Inquiry recommendation
82match
R15 - CDI patient observations records
Health Boards should ensure that nursing staff caring for a patient with CDI keep accurate records of patient observations including temperature, pulse, respiration.
Matched on
terms: patient, record
Inquiry recommendation
82match
R38 - Medical record keeping
Health Boards should ensure that clear, accurate and legible patient records are kept by doctors, that records are seen as integral to good patient care.
Matched on
terms: patient, record
Inquiry recommendation
78match
R20 - Stool records for CDI patients
Health Boards should ensure that where a patient has, or is suspected of having, C.difficile diarrhoea a proper record of the patient's stools is kept.
Matched on
terms: patient, record
Inquiry recommendation
78match
R14 - Patient records compliance audit
Health Boards should ensure that the nurse in charge of each ward audits compliance with the duty to keep clear and contemporaneous patient records.
Matched on
terms: patient, record
Inquiry recommendation
78match
IBI-4d - Patient Records Audit
Patient Records: Before the end of 2027 there should be a formal audit, publicly reported, of the extent of success of digitisation of patient records in each of the four health jurisdictions of the UK, measuring at least the levels of patient access to their personal records, their ability to identify and correct apparent errors in them, their...
Matched on
terms: patient, record
Inquiry recommendation
74match
R25 - Accessible financial records
The records kept must be easy to manage by staff and easily comprehensible to others, including people with learning disabilities and autistic people, carers and relatives.
Matched on
terms: record
Inquiry recommendation
73match
COVID-M3.4 - Data Systems for High-Risk Individuals
The UK government, Scottish Government, Welsh Government and Northern Ireland Executive must ensure that health data and digital systems have the capability to identify individuals at high risk of morbidity or mortality from a pandemic disease quickly and accurately in a future pandemic. This should include action to improve health data systems and patient record-keeping by: improving patient...
Matched on
terms: patient, record
Inquiry recommendation
69match
R19 - ICN instructions recorded
Health Boards should ensure that where Infection Control Nurses provide instructions on the management of patients those instructions are recorded in patient notes.
Matched on
terms: patient, record
Inquiry recommendation
69match
R24 - TVN instructions recorded
Health Boards should ensure that where a TVN is involved in caring for a patient there is a clear record in the patient notes and care plan of the instructions given.
Matched on
terms: patient, record
Inquiry recommendation
69match
R22 - Relative discussions recorded
Health Boards should ensure that any discussion between a member of nursing staff and a relative about a patient which is relevant to the patient's continuing care is recorded.
Matched on
terms: patient, record
Inquiry recommendation
65match
R27 - Positional change records
Health Boards should ensure that where a patient requires positional changes nursing staff clearly record this on a turning chart or equivalent.
Matched on
terms: patient, record
Inquiry recommendation
64match
IHRD-26 - Recording Clinical Discussions
Clinical notes should always record discussions between clinicians and parents relating to patient care and between clinicians at handover or in respect of a change in care.
Matched on
terms: patient, record
Inquiry recommendation
63match
SP50 - Healthcare trust risk information visibility
The Department of Health and Social Care / NHS England should ensure that all healthcare trusts involved in the care of children and young people who are at risk of acts of violence against others have systems that ensure that: 1. Key information regarding current and historic risk information is readily visible to treating clinicians in a summarised...
Matched on
terms: patient, record
Inquiry recommendation
61match
85 - Access to records for former child migrants
The Chair and Panel have recommended that all institutions which sent children abroad as part of the child migration programmes should ensure that they have robust systems in place for retaining and preserving any remaining records that may contain information about individual child migrants, and should provide easy access to them.
Matched on
terms: record
Inquiry recommendation
61match
38 - Improve perinatal mortality recording
Mortality recording of perinatal deaths is not sufficiently systematic, with failures to record properly at individual unit level and to account routinely for neonatal deaths of transferred babies by place of birth. This is of added significance when maternity units rely inappropriately on headline mortality figures to reassure others that all is well. We recommend that recording systems...
Matched on
terms: record
Inquiry recommendation
57match
R24 - Clear records and disclosure policies
Policies must be specific as to records to be kept and for routes to disclosure for relevant family members and people with learning disabilities and autistic people themselves where possible.
Matched on
terms: record
Inquiry recommendation
57match
BRIS-17 - Ensure patients receive copies of all inter-professional letters about their care
Patients should receive a copy of any letter written about their care or treatment by one healthcare professional to another.
Matched on
terms: patient
Inquiry recommendation
56match
LAMI-12 - Require front-line staff to record basic child information at first contact
Front-line staff in each of the agencies which regularly come into contact with families with children must ensure that in each new contact, basic information about the child is recorded. This must include the child’s name, address, age, the name of the child’s primary carer, the child’s GP, and the name of the child’s school if the child...
Matched on
terms: record
Inquiry recommendation
56match
BRIS-7 - Regularly update and pilot patient information materials with active patient involvement
Various modes of conveying information, whether leaflets, tapes, videos or CDs, should be regularly updated, and developed and piloted with the help of patients.
Matched on
terms: patient
Inquiry recommendation
53match
R26 - Six-monthly financial accounts to families
Information about the use of cash and other property and six-monthly accounts (or such period as appropriate upon discharge of the person) should be available to the service user concerned where possible and to the family where appropriate. Where appropriate an Easy Read version should be made available.
Matched on
classifier match
Inquiry recommendation
53match
R22 - Easy Read documents
All documents relevant to the service user’s experience and intended for their information must be made available in Easy Read format.
Matched on
classifier match
Inquiry recommendation
52match
R6 - Named person approval for transfers
The named person responsible for the care plan must both review and approve the preparation of anyone with a learning disability transferring to a new environment within or external to the Trust in which they are cared for. This approval must be recorded in the healthcare notes.
Matched on
terms: record
Inquiry recommendation
52match
BRIS-8 - NHS Modernisation Agency to prioritise patient information quality and establish accreditation system
The NHS Modernisation Agency should make the improvement of the quality of information for patients a priority. In relation to the content and the dissemination of information for patients, the Agency should identify and promote good practice throughout the NHS. It should establish a system for accrediting materials intended to inform patients.
Matched on
terms: patient
Inquiry recommendation
52match
BRIS-6 - Provide evidence-based patient information in a comprehensible summary format
Information should be based on the current available evidence and include a summary of the evidence and data, in a form which is comprehensible to patients.
Matched on
terms: patient
Inquiry recommendation
52match
AS-5 - Detainee Capture and Condition Records
Appropriate procedures should be introduced to ensure that there is an accurate and detailed contemporaneous record of the circumstances relating to the original capture/detention of a prisoner and his general physical condition (including an appropriate photographic record) on arrival at the Prisoner Handling Area together with an explanation from the soldier responsible for the detention of the individual...
Matched on
terms: record
Inquiry recommendation
52match
R30 - Fluid balance monitoring
Health Boards should ensure that where patients require fluid monitoring as part of their critical care, nursing staff complete fluid balance charts as accurately as possible.
Matched on
terms: patient
Inquiry recommendation
48match
R10 - CDI patient information
Health Boards should ensure that patients diagnosed with CDI are given information by medical and nursing staff about their condition and prognosis.
Matched on
terms: patient
Inquiry recommendation
44match
R26 - Wound documentation
Health Boards should ensure that where a patient has a wound or pressure damage there is clear documentation of the nature of the wound or damage in accordance with best practice guidance.
Matched on
terms: patient
Inquiry recommendation
44match
IHRD-24 - Blood Test Result Documentation
All blood test results should state clearly when the sample was taken, when the test was performed and when the results were communicated and in addition serum sodium results should be recorded on the Fluid Balance Chart.
Matched on
terms: record
Inquiry recommendation
44match
R29 - Patient weighing equipment
Health Boards should ensure that there is appropriate equipment in each ward to weigh all patients. Patients should be weighed on admission and at least weekly thereafter.
Matched on
terms: patient
Inquiry recommendation
40match
R13 - Full staff access to care plans
All staff involved in delivering care, including healthcare assistants (HCAs), must have full access to the care plan.
Matched on
classifier match
Inquiry recommendation
39match
AS-9 - Medical Fitness for Detention Forms
Appropriate forms should be made available to allow a medical examiner to declare a detainee unfit for detention and questioning. The decision as to whether a detainee has been declared unfit for detention and questioning should be readily apparent and the reasons for that decision should be recorded. Any conclusion to the contrary effect should be expressed in...
Matched on
terms: record
Inquiry recommendation
36match
BRIS-18 - Provide parents of young children with copies of all inter-professional healthcare letters
Parents of those too young to take decisions for themselves should receive a copy of any letter written by one healthcare professional to another about their child’s treatment or care.
Matched on
classifier match
Inquiry recommendation
35match
BRIS-9 - Develop kitemarking system for reliable internet health information guidance for public
The public should receive guidance on those sources of information about health and healthcare on the Internet which are reliable and of good quality: a kitemarking system should be developed.
Matched on
classifier match
Inquiry recommendation
31match
R39 - DNAR decision awareness
Health Boards should ensure that medical and nursing staff are aware that a DNAR1 decision is an important aspect of care.
Matched on
classifier match
Inquiry recommendation
31match
R18 - Care planning system
Health Boards should ensure that there is an agreed system of care planning in use in every ward with the appropriate documentation available to nursing staff.
Matched on
classifier match