Feel like you are walking through a minefield waiting to be tripped up now that more standards have changed? A few tips this month on some aspects of documentation to support what you already do……. And some help if you don’t.
“If it isn’t written down it didn’t happen”, Consider: –
- The updated HCPC Standards of Conduct, Performance, and Ethics (CPE) – can you evidence the examples selected below?
- How you document you provided anything that is not linked to your notes system e.g. videos, advice leaflets, etc.
- How do you meet your legal requirement to take notes? This is part of the service you provide – a few considerations.
- What format should your clinical documentation follow?
- Which abbreviations are acceptable in our documentation?
Let’s start with the overarching statement from the HCPC.
Once you are registered with us, you have a professional responsibility to keep full, clear, and accurate records for everyone you care for, treat, or provide other services to. Our expectations for your record keeping |
From the latest update to the Standards of conduct, performance and ethics |(2024)- can you evidence the examples below?
Standard 1.4 You must make sure that you have valid consent, which is voluntary and informed, from service users who have capacity to make the decision or other appropriate authority before you provide care, treatment or other services. –
Documents you could use – your policy, processes and patient information leaflet should reflect this, check your evidence is robust.
Standard 2.2 You must listen to service users and carers and take account of their needs and wishes.
Document how you adapt your communication style and methods to the service user. You could use your EDI reasonable adjustment information here too, think braille, sign language, interpreters, etc. (You do not need to change information unless required, but you need to evidence you know where, and how, you would do it if the need arose e.g. a checklist of providers to use)
Standard 8.4 You must give a helpful and honest response to anyone who complains about the care, treatment or other services they have received.
Documents you could use a complaints tracker could provide evidence and be a summary of this. Your process, how to complain leaflet, reflective learning sheet (after the event) could all be used as evidence supporting 8.4.
10.2 You must complete all records promptly and as soon as possible after providing care, treatment or other services.
Document how you audit notes to ensure all treatments are recorded. How you audit to check that notes are completed contemporaneously* – spot check at random 48 hours after the session to see they are completed and keep the evidence.
The HCPC states the practice, and a standard format is not specified but is likely to be specific to your profession and your place of work. Standards of proficiency |(2023).
It also stipulates you must: –
Standard 9.1 keep full, clear and accurate records in accordance with applicable legislation, protocols and guidelines
9.2 manage records and all other information in accordance with applicable legislation, protocols and guidelines
Document how you manage the processes or a flow chart could be used. Remember that the records should be accessed, retained, stored, transported and destroyed according to the legal requirements and policies should also exist to determine this.
Remember abbreviations can be used but a list for the service should exist.
And a final tip………… Keep it brief, clear, and stored appropriately AND if in doubt, write it out.
We can help you work through any of the steps above, answer your queries, or provide templates to help. Book a free HCPG/virtual-cuppa via this link to share ideas.
The Offer of the Month is Notes Audit Template this link goes to our store.
To stay up to date with HCPC compliance click here.
