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
Source spread
Where this theme appears
Inaccurate and inaccessible patient records has been flagged across 1 independent accountability source:
37 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
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Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (37)
R26 — Six-monthly financial accounts to families
Recommendation: 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 …
Response Pending
R25 — Accessible financial records
Recommendation: 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.
Response Pending
R22 — Easy Read documents
Recommendation: All documents relevant to the service user’s experience and intended for their information must be made available in Easy Read format.
Response Pending
COVID-M3.4 — Data Systems for High-Risk Individuals
Recommendation: 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 …
Gov response: No formal response published by this government.
Unknown
R38 — Medical record keeping
Recommendation: 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.
Gov response: Section 4.2 of the Scottish Government's response directly addresses recommendation 38, which relates to clear, accurate, and legible patient records kept by doctors, emphasizing their integral role in good patient care. The General Medical Council …
Accepted
85 — Access to records for former child migrants
Recommendation: 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 …
Gov response: Between January and July 2020, Action for Children, Barnardo's, Catholic Church in England and Wales, Cornwall Council, Father Hudson's Care, Salvation Army UK, Sisters of Nazareth, The Children's Society and The Prince's Trust committed to …
Accepted
R24 — Clear records and disclosure policies
Recommendation: 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.
Response Pending
R13 — Full staff access to care plans
Recommendation: All staff involved in delivering care, including healthcare assistants (HCAs), must have full access to the care plan.
Response Pending
R6 — Named person approval for transfers
Recommendation: 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 …
Response Pending
R20 — Stool records for CDI patients
Recommendation: 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.
Gov response: Section 4.2 of the Scottish Government's response outlines the professional standards for record-keeping for nurses. The revised NMC code requires nurses and midwives to complete all records accurately and without any falsification, and to identify …
Accepted
R19 — ICN instructions recorded
Recommendation: Health Boards should ensure that where Infection Control Nurses provide instructions on the management of patients those instructions are recorded in patient notes.
Gov response: Section 4.2 of the Scottish Government's response details the professional standards for record-keeping for nurses and doctors. The revised NMC code requires nurses and midwives to complete all records at the time or as soon …
Accepted
R15 — CDI patient observations records
Recommendation: Health Boards should ensure that nursing staff caring for a patient with CDI keep accurate records of patient observations including temperature, pulse, respiration.
Gov response: Section 4.2 of the Scottish Government's response outlines professional standards for record-keeping. The revised NMC code, which all nurses and midwives must follow, specifically requires them to complete all records accurately and without any falsification, …
Accepted
R14 — Patient records compliance audit
Recommendation: Health Boards should ensure that the nurse in charge of each ward audits compliance with the duty to keep clear and contemporaneous patient records.
Gov response: Section 4.2 of the Scottish Government's response details professional standards for record-keeping, with the revised NMC code requiring nurses and midwives to maintain clear, accurate, and contemporaneous records. While the text does not explicitly state …
Accepted
F244 — Common information practices shared data and electronic records
Recommendation: 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 …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
IBI-4d — Patient Records Audit
Recommendation: 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 …
Gov response: NHS England's Frontline Digitisation programme aims for all secondary care trusts to have electronic patient record systems. Plans exist to publicly report findings by summer 2025. Scotland will expand Digital Maturity Assessments by 2025 for …
Accepted
No update 2+ yrs
BRIS-18 — Provide parents of young children with copies of all inter-professional healthcare letters
Recommendation: 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.
Unknown
BRIS-17 — Ensure patients receive copies of all inter-professional letters about their care
Recommendation: Patients should receive a copy of any letter written about their care or treatment by one healthcare professional to another.
Unknown
R30 — Fluid balance monitoring
Recommendation: 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.
Gov response: Section 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code, which nurses must follow, provides specific guidance requiring clear and accurate records to be maintained. Nurses must …
Accepted
R27 — Positional change records
Recommendation: Health Boards should ensure that where a patient requires positional changes nursing staff clearly record this on a turning chart or equivalent.
Gov response: Section 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code, which nurses must follow, provides specific guidance requiring clear and accurate records to be maintained. Nurses must …
Accepted
R26 — Wound documentation
Recommendation: 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.
Gov response: Section 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code requires nurses to maintain clear and accurate records, completing them as soon as possible after an event …
Accepted
R24 — TVN instructions recorded
Recommendation: 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.
Gov response: Section 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code, which nurses must follow, requires clear and accurate records to be maintained, completed at the time of …
Accepted
R22 — Relative discussions recorded
Recommendation: 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.
Gov response: Section 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code, effective from March 2015, requires nurses and midwives to complete clear and accurate records at the time …
Accepted
IHRD-24 — Blood Test Result Documentation
Recommendation: 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.
Gov response: Blood test documentation standards updated. Serum sodium recording on fluid balance charts implemented.
Accepted
38 — Improve perinatal mortality recording
Recommendation: 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 …
Gov response: 103. We accept this recommendation. We will explore the feasibility of publishing data about the safety and quality of maternity services at individual Trust level. 104. As recommended by the Morecambe Bay Report, MBRRACE-UK has …
Accepted
SP50 — Healthcare trust risk information visibility
Recommendation: 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: …
Gov response: The Department of Health and Social Care (DHSC) and NHS England are the lead organisations. Progress and next steps: - The Single Patient Record is currently being designed and scoped. - This is part of …
Accepted
In progress
LAMI-12 — Require front-line staff to record basic child information at first contact
Recommendation: 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 …
Unknown
BRIS-9 — Develop kitemarking system for reliable internet health information guidance for public
Recommendation: 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.
Unknown
BRIS-8 — NHS Modernisation Agency to prioritise patient information quality and establish accreditation system
Recommendation: 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. …
Unknown
BRIS-7 — Regularly update and pilot patient information materials with active patient involvement
Recommendation: Various modes of conveying information, whether leaflets, tapes, videos or CDs, should be regularly updated, and developed and piloted with the help of patients.
Unknown
BRIS-6 — Provide evidence-based patient information in a comprehensible summary format
Recommendation: 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.
Unknown
R39 — DNAR decision awareness
Recommendation: Health Boards should ensure that medical and nursing staff are aware that a DNAR1 decision is an important aspect of care.
Gov response: Section 4.1 of the Scottish Government's response notes that recommendation 39 focuses on the clinically and ethically challenging aspects of Do Not Attempt Cardiopulmonary Resuscitation (DNAR) orders. The report sets out precise standards for decision-making, …
Accepted
R18 — Care planning system
Recommendation: 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.
Gov response: Section 4.2 of the Scottish Government's response details professional standards for record-keeping, with the revised NMC code requiring nurses and midwives to maintain clear and accurate records. This includes identifying any risks or problems and …
Accepted
IHRD-26 — Recording Clinical Discussions
Recommendation: 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.
Gov response: Documentation standards updated to require recording of clinical discussions and handovers.
Accepted
AS-9 — Medical Fitness for Detention Forms
Recommendation: 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 …
Gov response: Sir Thayne Forbes has made just nine recommendations, and he acknowledges the progress that the Ministry has made since 2004 to improve all aspects of the prisoner-handling system—from policy and doctrine to unit-level instructions and …
Accepted
AS-5 — Detainee Capture and Condition Records
Recommendation: 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 …
Gov response: Sir Thayne Forbes has made just nine recommendations, and he acknowledges the progress that the Ministry has made since 2004 to improve all aspects of the prisoner-handling system—from policy and doctrine to unit-level instructions and …
Accepted
R29 — Patient weighing equipment
Recommendation: 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.
Gov response: Section 3.1 of the Scottish Government's response addresses the need for appropriate equipment by detailing investment in NHS estates, assets, facilities, and equipment. The government has committed over £400 million to improve NHS infrastructure between …
Accepted
R10 — CDI patient information
Recommendation: Health Boards should ensure that patients diagnosed with CDI are given information by medical and nursing staff about their condition and prognosis.
Gov response: Section 4.2 of the Scottish Government's response highlights initiatives promoting person-centred care, including the 'Must Do with Me' elements, which emphasize 'what information do you need?' and patient involvement in decisions. The response also details …
Accepted