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Digital Record Keeping (England) Policy

Policy Statement

This policy sets out the values, principles and procedures underpinning this care service’s approach to the keeping of digital records of people who use the services. It should be read alongside the service’s other policies on record keeping, information governance and data protection and security.

This service is committed to the secure, efficient and compliant management of its digital records. It expects that the digital tools it uses will enable the service to continue to comply with all regulatory and good practice requirements.

Every care service is required to have systems and methods for keeping records that comply with Regulation 17: Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This regulation states that the registered person must:

• maintain securely an accurate, complete and contemporaneous record in respect of each person, including a record of the care and treatment provided to the person receiving care, and of decisions taken in relation to the care and treatment provided
• maintain securely such other records as are necessary to be kept in relation to:
a) persons employed in the carrying on of the regulated activity
b) the management of the regulated activity.

Principles of Digital Record Keeping

• Records shall be maintained in a secure, encrypted format to protect against unauthorised access and breaches.
• All digital records shall be stored on secure servers, and backed up every __________.
• Staff members will receive training, according to their role, on record keeping procedures including data protection, privacy and retention.
• Records shall be regularly reviewed and updated to ensure accuracy and relevance.
• People using services shall be informed of their rights regarding access to their own records, and those records should meet the person’s accessibility requirements.
• Any breaches, errors or discrepancies in digital records shall be promptly reported and documented.

Responsibilities

Management

The manager responsible for ensuring the implementation, development and ongoing review of digital record keeping system(s), and the procedures for their use, is ______________________.

Data protection and information governance is the responsibility of _____________________.

The issuing and maintenance of devices is the responsibility of _______________________.

Care staff and assessors

All staff involved in the making or keeping of care records are responsible for:

• accurately and promptly entering records
• maintaining confidentiality
• following security procedures
• reporting any concerns or errors.

Training

New staff must read and understand this policy and those on record keeping, data protection and confidentiality as part of their induction.

All staff receive training covering how to use the service’s digital records keeping system in accordance with their role.

All staff who need to use digital system(s) are trained to protect people’s private data, to ensure data security, and to understand the consequences to them as individuals and the organisation of any potential lapses and breaches of the service’s policies and procedures.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}

Reviewed on: {{last_update_date}}

Next Review Date: {{next_review_date}}

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