Staff Guidance on Data Quality & Record Keeping

April 24th 2019

This guidance is relevant to staff who have responsibility for creating care or personnel records. The guidance should match the procedures you have in your organisation and should be supported with proper training.

You can download a word version of this guidance below and adapt it to meet your needs.

1.    Introduction

Good quality, accurate records are vital for the safety of our service users and the safe and responsible running of our organisation.

When you create or update a record you must ensure that the information you enter has the following characteristics: –

1. It is authentic – i.e. the data is what is claims to be. You can make sure it is authentic by properly signing off records you have updated with your name and marking the time and date.
2. It is reliable. You should make sure you record data which is complete and accurate and that you write it down as soon after the (or during) the event as possible.
3. It has integrity. If you need to change any information, make sure that it is clearly marked and that you can be identified as the person who has changed the record. If you have questions ask your line manager
4. It is useable. To use a record we need to be able to find it! Make sure that you replace records where they should be kept. You might like to say where you store records here, or where they are saved if they are digital records. Provide as much context as you can so that your records can be easily understood.

When we create records, we use standardised structures and layouts for the contents of records.

You should provide more detail on record creation. If you use paper forms, where can these be found? If you use a digital system make sure that you provide adequate training to your staff so that they know how to use it properly.

We monitor and audit our records throughout their lifetime to make sure they follow the four characteristics above. We have a Data Quality Policy and Record Keeping Policy which can be located insert location here. Failure to comply with these policies may result in disciplinary action. If you would like more training on how to accurately collect and record data please speak to your line manager.