By Bethany Hemsley
To achieve a good digital record system, providers should have records that are person-centred, accessible and accurate, says CQC in its new guidance.
The guide explains what good digital records look like and how providers can achieve this. It also covers what CQC will look at on inspection.
Digital records systems are beneficial for people who use the services, for providers and for the broader health and care system by providing ‘real time’ information regarding a person’s required care and support.
Digital care records also reduce risks of medication errors, allow data to be compared and can help carers to respond to people’s changing needs more quickly.
For these benefits to be seen in care settings, the digital systems must be implemented effectively.
Digital systems should be:
- Up to date
- Always available
It is the provider’s choice whether they use paper or digital systems, or a mixture of both. However, all records must comply with:
- Regulation 17 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
- Data protection legislation (including GDPR) requirements
- Accessible Information Standard
- Data Security and Protection Toolkit (where providers have access to NHS patient data and systems).
As a result of COVID-19, CQC may request more information in a digital format, such as asking for access to digital care records when not on site.
During inspections, providers should give the inspector guest log-in details and support the inspectors to access any records they need to see. Providers cannot refuse to show any records when requested without a valid reason.
Read the full guidance for more information on establishing and maintaining good digital records and what to expect from a CQC inspection.