Inaccurate and inaccessible patient records
Failure to maintain easily accessible, up-to-date, and accurate information about patients/service users in care settings.
62 items
1 source
16 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
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. Health Boards should ensure that there is an appropriate form of charting of stools available to enable nursing staff to provide the date, time, size and nature of the stool. Stool charts...
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, oxygen saturation and blood pressure.
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, and that they are routinely audited by senior medical staff.
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. Health Boards should ensure that there is an effective system of audit of patient records, and that there is effective scrutiny of audits by the Board.
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
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 the patient notes and are included in care planning for the patient.
Matched on
terms: patient, 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
73match
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 in the patient’s notes to ensure that those caring for the patient are aware of the information given.
Matched on
terms: patient, record
Inquiry recommendation
70match
12 - Review and update medical records
The Chief Executive and the Trust Board shall review and update medical and pathology records to include, preferably on computer and cross-referenced, the following information: – name, medical record reference number and date of birth; – date, place of death and death certificate; – name and address of next of kin; – whether Coroner’s or hospital post mortem...
Matched on
terms: 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 for management of the patient.
Matched on
terms: patient, record
Inquiry recommendation
66match
11 - Review records and develop audit trail
Records should be reviewed and updated and an audit trail should be developed and put in place.
Matched on
terms: 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. Compliance should be monitored by a system of audit.
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
62match
17 - Moratorium if records inadequate
a moratorium must be declared if records of organ retention are inadequate during which there should be an immediate cataloguing of organs retained;
Matched on
terms: record
Inquiry recommendation
62match
15 - Hospital records of organs and tissue
every hospital keep proper records (preferably computerised) as to the source, consent to retain, usage and disposal of organs and tissue;
Matched on
terms: record
Inquiry recommendation
62match
14 - University records track organ use
University records shall identify receipt, use, dispersal and ultimate disposal of any organ or sample.
Matched on
terms: record
Inquiry recommendation
62match
13 - University audit trail to clinical record
University records shall provide a confidential audit trail back to the clinical record.
Matched on
terms: record
Inquiry recommendation
61match
24 - NOMIS to record facts of offences
Information about a prisoner’s convictions and outstanding charges held on NOMIS should include a short statement of the facts of each offence or charge.
Matched on
terms: record
Inquiry recommendation
61match
85 - Access to records for former child migrants
We therefore recommend that 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
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
R30 - Fluid balance monitoring
Health Boards should ensure that where patients require fluid monitoring as part of their clinical care, nursing staff complete fluid balance charts as accurately as possible and sign them off at the end of each 24-hour period.
Matched on
terms: patient
Inquiry recommendation
48match
14 - Recording cell-share requests
The guidelines should contain guidance on how such requests should be recorded, but there is no need for such requests to be treated as formal applications under the requests and complaints procedures.
Matched on
terms: record
Inquiry recommendation
46match
18 - School information on children in writing
Any information about children which is to be used for the purposes of their compulsory care and which is provided by their school-teacher should be provided in writing (15.38).
Matched on
classifier match
Inquiry recommendation
44match
29 - Content of NOMIS staff training
The training which staff receive on NOMIS should not merely address how to log on, enter information and retrieve it. It should reinforce the need for any information which is to be entered to be accurate, comprehensive and unambiguous. It should also reinforce the need for all staff to be aware of the background and offending history of...
Matched on
classifier match
Inquiry recommendation
44match
34 - Report unresolved problems to regional office
If no solution is found after all diligent attempts, the parties should keep records of their attempts and the reasons why they have failed, such records to be lodged by way of report to the relevant NHS Executive Regional Office.
Matched on
terms: record
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, including the cause, grade, size and colour of the wound or damage. The pressure damage or wound should be reassessed regularly according to the patient’s condition....
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
40match
33 - Policy on disclosing medical reports to prisons
In the light of such legal advice as the Courts Service receives, it should publish a policy on the disclosure to the prison of medical or psychiatric reports on a prisoner submitted to the court.
Matched on
classifier match
Inquiry recommendation
40match
25 - NOMIS flag for change of status date
If a convicted prisoner is not due to be released when they complete their sentence because they were remanded in custody awaiting trial on other charges, NOMIS should flag up the date on which their change of status is due to occur.
Matched on
classifier match
Inquiry recommendation
40match
5 - Operating systems (interoperability)
NHS England must provide, by 31 March 2027, a clear and timed route to ensuring that computer systems are harmonised across the NHS by December 2028. Work on the development of a mandatory information standard with requirements for interoperability between systems should be taken forward and implemented as soon as possible. This should mean that data relating to...
Matched on
classifier match
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
40match
28 - Avoiding information overload; terminals for NOMIS
Information overload should be avoided by enabling officers to get to the information they need quickly and to bypass the information they do not need. The technology should be up to date, and sufficient terminals should be provided to ensure that staff have ready access to NOMIS at all times.
Matched on
classifier match
Inquiry recommendation
36match
40 - Written notice to wings of prisoner arrival
All establishments should have a procedure for notifying wings in writing that a prisoner is currently charged with, or has been convicted of, an offence under the Protection from Harassment Act 1997.
Matched on
classifier match
Inquiry recommendation
36match
38 - Wing files required for admission to wing
Prisoners should not be admitted to a wing without their current wing file, save with the permission of a governor or the approval of the night orderly officer. Important entries in it should be made in red.
Matched on
classifier match
Inquiry recommendation
36match
37 - Checklist for files on transfer
To ensure that all files accompany prisoners on their transfer to another establishment, they should be ticked off at the reception of the sending establishment against a checklist. Prisoners should not be allowed to leave unless all their files have been ticked as present, except with the permission of a governor. Staff on reception at the receiving establishment...
Matched on
classifier match
Inquiry recommendation
36match
36 - Telling receiving prison reason for transfer
Whenever a prisoner is transferred to another establishment, the receiving establishment should be told what the reason for the transfer is. If the transferring prisoner is a particularly problematic one, the receiving establishment should be warned beforehand.
Matched on
classifier match
Inquiry recommendation
36match
35 - Police National Computer link to prisons
The Police National Computer should be linked to the whole of the prison estate. In the meantime, any intelligence the police may have about prisoners which could affect their management in prison should be sent to the police liaison officers for the establishments at which the prisoners are being held. A decision can then be made whether the...
Matched on
classifier match
Inquiry recommendation
36match
34 - Facts of offences in conviction lists
The list of a prisoner’s convictions sent to the prison should include a short statement of the facts of each offence and the charges the prisoner is facing.
Matched on
classifier match
Inquiry recommendation
36match
32 - Transcripts of judges' remarks to prison
When a judge asks for any remarks which they make to be brought to the attention of the Prison Service, the court should assume responsibility for commissioning a transcript of what has been said and sending a copy to the prison.
Matched on
classifier match
Inquiry recommendation
36match
30 - Reports accompanying prisoners from court
To avoid prisoners leaving court without being accompanied by bail information reports or pre-sentence reports, the probation officer should ensure that a copy of the report is available for the escort contractor, and there should be someone in court whose responsibility it is to ensure that the dock officer gets it. Escort contractors should have a list of...
Matched on
classifier match
Inquiry recommendation
36match
26 - Security Departments entering shareable information on NOMIS
Although there are no plans for security information to be entered onto NOMIS in its first phase, Security Departments should enter any information which can be shared with the majority of staff when the first phase of NOMIS becomes operational.
Matched on
classifier match
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
32match
31 - Court responsibility for warrant and conviction documents
There should be someone in court whose responsibility it is to ensure that the dock officer gets copies of the warrant authorising the prisoner’s detention, the list of their convictions, and the indictment or charge sheet.
Matched on
classifier match