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8.2.2 Data Quality and Record Keeping

AMENDMENT

This chapter was updated in April 2015.


Contents

  1. General
  2. Data Quality
  3. Auditing
  4. Electronic Records
  5. Paper Records
  6. Storage and Archiving


1. General

  • It is expected that all staff will record accurately all information relating to a service user; 
  • All service users must have records; these may be electronic, paper or both. All records must be ordered, complete and accessible;  
  • A service user record can be called on for legal purposes. This includes evidence in court, complaints and internal investigations;
  • You must always check if a new service user is already known to Adult Social Care and check if they have a paper or an electronic file;   
  • All entries to records must be signed and dated, all electronic records must have a name and a date on them.


2. Data Quality

The Corporate Strategy makes clear the reasons why high quality data is required and defines the key elements of data quality as follows;

Good quality data should be: Accurate, Valid, Reliable, Timely, Relevant & Complete.

In Adult Social Care we recognise that high quality data is essential if we are to:

  • Support positive outcomes for our service users & carers;
  • Keep services users safe;
  • Commission the services that will meet the needs and aspirations of our users;
  • Deliver and demonstrate that we ensuring value for money in our services;
  • Ensure that we deliver financial balance each year;
  • Have effective performance management systems in place;
  • Support the development of our workforce.

The Adult Social Care Data Quality Policy provides detailed guidance on what our responsibilities are in relation to Data Quality and what Governance arrangements we have in place to support it.


3. Auditing

It is expected that managers will routinely audit the quality and accuracy of the information held within records.


4. Electronic Records

All service users should have an up to date and complete CareFirst electronic record.


5. Paper Records 

Where a service user has a paper file there must also be an electronic record.

Service users may also have a Person Held record (a yellow file) that is kept in their home. This remains their property at the end of the episode of care.


6. Storage and Archiving

Both electronic and paper files must be stored securely.

Different records need to be kept for different lengths of time. For further information see the information on Archiving.

Click here to view Retention and Destruction of Records Procedure, Appendix 1: Records Retention Schedule for Adult Social Care

Click here to View Deepstore online User Guide

End