- Why is it important to keep accurate patient records?
- Why is accurate and consistent recording of medication important?
- What are three examples of poor documentation practices in patient records?
- Where are patient records stored?
- Why records in the pharmacy should be accurate?
- Why is documentation important in pharmacy?
- How long do pharmacy records need to be kept?
- How do you maintain patient records?
- Who is the legal owner of the patient’s medical record?
Why is it important to keep accurate patient records?
For health professionals, good medical records are vital for defending a complaint or clinical negligence claim; they provide a window on the clinical judgment being exercised at the time.
The presence of a complete, up-to-date and accurate medical record can make all the difference to the outcome..
Why is accurate and consistent recording of medication important?
The main reason for maintaining medical records is to ensure continuity of care for the patient. They may also be required for legal purposes if, for example, the patient pursues a claim following a road traffic accident or an injury at work.
What are three examples of poor documentation practices in patient records?
Examples of medical documentation errorsSloppy or illegible handwriting.Failure to date, time, and sign a medical entry.Lack of documentation for omitted medications and/or treatments.Incomplete or missing documentation.Adding entries later on.Documenting subjective data.Not questioning incomprehensible orders.More items…•
Where are patient records stored?
Hardcopy records should be stored in a locked filing cabinet or in a secured dedicated room at the practice, or by a secure storage provider. You must take all reasonable steps to protect the security of your medical records.
Why records in the pharmacy should be accurate?
It is important that records are complete, accurate and up to date. Full details for the patient and the prescriber should be recorded so that they can be clearly identified and contacted if needed. Pharmacists should be alert to any errors or discrepancies in pharmacy records.
Why is documentation important in pharmacy?
Today, pharmacy professionals are not only expected to gather the information needed to assess the patient and the prescription, they must also keep a reliable and easily-retrieved record of this information. Documentation of what is clinically relevant is vital to continuity of patient care.
How long do pharmacy records need to be kept?
All records of prescriptions dispensed must be retained for two years from the date of dispensing and must be kept on the premises where the prescription was dispensed.
How do you maintain patient records?
Principles of Good Record KeepingBe factual, consistent and accurate;Be updated as soon as possible after any recordable event;Provide current information on the care and condition of the patient;Be documented clearly in such a way that the text cannot be erased;More items…•
Who is the legal owner of the patient’s medical record?
The overriding duty is to ensure that patient confidentiality is maintained and that records are not lost, stolen, damaged or altered. Who owns the medical records? Unless there are specific contractual arrangements, medical records generally belong to the medical practice or hospital in which they were created.