RCSLT Guidance and keeping records of your work

RCSLT guidance to support members to adhere to the HCPC standards


Access the downloadable, PDF version

Speech and language therapists:

Keep records accurate

  1. Have clear record keeping procedures that are monitored and reviewed, in line with current legislation whatever context they work in. 
  2. Have procedures for the creation, use, secure storage and appropriate sharing of records, in line with current legislation.
  3. Monitor and review these procedures.
  4. Keep records that are fit for purpose and offer clear reasoning for decision making.
  5. Record evidence of clinical reasoning and decision making.
  6. Manage records according to all relevant legislation, guidance or policies – national and local. 
  7. Have systems in place for auditing records of work.
  8. Clearly identify the service user throughout the record, according to local policy and practice.
  9. Write care records that are objective and concise.
  10. Write their care records promptly, as soon as practically possible after the activity occurred.
  11. Sign and date all care record entries, using the date the service user was seen and the date the entry was made, if different. 
  12. Write care records chronologically.
  13. Make any changes or corrections to care records clearly.
  14. Identify themselves as the author of their care record entries.

Keep records secure

  1. Keep and manage records securely and dispose of them according to legal requirements (eg Data Protection Act) and local policy as appropriate.
  2. Ensure electronic recording systems and diaries (mobile phones, personal digital assistants, computers) used for work purposes adhere to legal and local data protection requirements.
  3. Keep their records, whether paper or electronic, safe from theft, loss, false access or damage.
  4. Transport records securely. 
  5. Do not leave records unattended in ways that are potentially insecure.
  6. Retain records for an appropriate period of time, as defined by their nature, content and purpose.
  7. Record evidence of consent or authorisation before identifiable service user information is shared. 
  8. Support service users’ access to their own care records, in accordance with legislation and local policy.
  9. Follow local policy or protocol where mental incapacity does not allow the gaining of consent to share service user information. 
  10. Have a protocol for secure information sharing with other organisations.

Footnote:

  • Service user – The term service user is used but the terms ‘patient’ or ‘client’ may also be appropriate 
  • Individual(s) – The term ‘individual’ has been used. Depending on the context provided in the sentence, this could refer to a service user, patient, client, colleague or carer.




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