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  7. Implement systems and processes for recording healthcare interventions

Implement systems and processes for recording healthcare interventions

This page is designed to answer the following questions:

NOTE: Although this page has been marked as complete, it has not yet been peer-reviewed or quality-assured, therefore it should be considered a ‘first draft’ and any information should be fact-checked independently.

For this assessment criterion, you will be required to critically review and evaluate operational systems and processes for recording health and care interventions with those in receipt of care.

This means examining in detail the systems and processes that your organisation currently uses to document service user’s healthcare, highlighting their strengths and weaknesses and making recommendations about how they could be improved.

To evidence an outcomes-based approach, your systems and processes should record the outcomes that have been agreed, how they were agreed and any progress that has been made. There should also be an area to record when outcomes are reviewed and what is discussed.

Similarly, there should be systems and processes for recording care planning and care plan reviews as well as any changes to an individual’s needs, wishes and preferences. Regular reviews and feedback about an individual’s healthcare should be arranged with the individual themselves, their family/carers and other stakeholders. You should have systems in place to record these discussions.

Documents from other agencies, such as the NHS, GP surgeries or social services will also need to be stored.

In recent years, healthcare documentation has evolved from handwritten records to digital records. If you are still using handwritten records, the system may no longer be fit-for-purpose and you may wish to look into implementing a computerised system.

Whether information is stored physically or digitally, all healthcare records will be confidential and so systems must be in place to ensure that only authorised individuals have access to them. All systems must be secure and comply with the Data Protection Act 2018 and GDPR.