Patient care records

All staff are reminded of the importance of PCRs and the following points:

• there should be a PCR for every attendance to a patient (that adheres to documentation standards)
• these should be submitted as soon as is possible to the management team on stations, if completed on paper
• paper PCRs should be stored at stations in a secure area (to prevent loss or data protection breaches)
• paper PCRs should be sent to the medical records departments within two weeks of being created.

The policy for PCRs can be found on the Trust’s website.

Tracy Nicholls, Director of Quality  said: “HCPC registration or best practice code of conduct could be at risk and not having a PCR makes it impossible to support staff in times of a complaint, incident or claim, as we have no record of the decisions you made and why.”

Managers are reviewing each shift log to ensure there is a PCR for each patient attended and staff who are currently working on alternate duties are also being placed within medical records to support PCR retrieval.

Please also remember that it is Trust policy to use electronic PCR at all times when available; these are secure, cannot be lost, and are instantly available to other clinicians, providers, and for investigations.