Record keeping

The PRSB work with people who use services, carers, nurses and other health professionals to define the information that is needed in a given situation when someone receives care. Their suite of standards tell providers what information should be recorded and shared and can work with any system in use locally.

The Data Protection Act 2018 is the UK law that governs how personal data is collected, processed, and stored, ensuring individuals’ privacy rights and aligning with UK GDPR.

The Care Certificate is an identified set of standards that health and social care workers adhere to in their daily working life.

The Francis Report, which examined the Mid Staffordshire NHS Foundation Trust, found failings in patient care, emphasizing that putting patients first must be the priority for all staff and organizations.

The 2014 Vale of Leven Hospital Inquiry Report detailed failures in leadership, management, and infection control practices that led to a Clostridium difficile (C. difficile) outbreak between 2007 and 2008.

This guidance sets the direction for all nursing documentation across hospitals, community and nursing homes. It is intended to help organisations implement record systems and policies which support nurses to produce good documentation that supports and evidences professional decision making and care, while minimising time spent on producing those records.

The SSSC Codes of Practice set out the standards of practice and behaviour expected of everyone who works in social services in Scotland and the standards expected of employers of social service workers in Scotland.

This eBook explores the various aspects of the knowledge and skills in communication you will need in order to be an effective social service worker. See chapter on recording and reporting.

This badge will help you to show what you have learned from the Recording and reporting chapter of the Communications and Relationships ebook in the Foundations for Practice series.

Key resources for clinical support workers across nursing, midwifery and allied health professions in NHS Scotland.

This Code of Conduct describes the standards of conduct, behaviour and attitude required of all Healthcare Support Workers employed within NHS Wales.

The Department has launched a suite of resources aimed at strengthening the vital role undertaken by our Nursing Assistants working in Northern Ireland HSC Trusts.

Information and resources have been produced through the FNFM programme of work to support nurses, midwives and their employers, as well as Universities and students.

The Social Care Council’s Standards of Conduct and Practice form the core regulatory framework for the social work and social care workforce.