This policy is fully drafted and structured, ready to brand and complete for your service. It covers:
1. Purpose
2. Scope
3. Policy statement and principles
4. Definitions
5. Legal, regulatory and professional framework
6. Content of a consultation record
7. Contemporaneous and timely recording
8. Accuracy, legibility and professional standards
9. Amendments, corrections and addenda
10. Electronic records and clinical systems
11. Paper records and hybrid working
12. Confidentiality, access and data protection
13. Retention and secure disposal
14. Record security and transfer
15. Roles and responsibilities
16. Training
17. Monitoring, audit and review
18. Related documents
19. Glossary
20. References
Legislation & standards it maps to
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Care Quality Commission (Registration) Regulations 2009
UK General Data Protection Regulation (UK GDPR)
Data Protection Act 2018
Access to Health Records Act 1990
General Medical Council: Good Medical Practice 2024
Nursing and Midwifery Council: The Code (2018)
Common Law Duty of Confidentiality
Who it applies to
All clinical, registered and administrative staff, temporary and locum workers, students, contractors and volunteers who create, access, amend, store or dispose of clinical records of [Organisation Name]
How it works
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Download your editable Word file from the link we email you straight away.
Complete the placeholders for your service, then have it approved before use.
Add the optional updates subscription and we keep it current as guidance changes.