Clinical Record Keeping Policy

1 SH CP 221 Clinical Record Keeping Policy Version 4 March 2018 SH CP 221 Clinical Record Keeping Policy Version 4 Summary: This Policy provides statements and standards for the management of Clinical information (electronic and paper) and assurance of compliance with national and legal requirements. Associated standards, procedures and guidance: SH IG 6 Approved Abbreviations Guidance SH IG 8 Mental Health Act Documentation Procedure Procedure and Consent Form for Communicating via email or text Guidance on Lasting Power of Attorney SH IG 12 Subject Access Request and Disclosure of Personal Data Procedure SH IG 13 Information Lifecycle Policy SH IG 18 Data Protection, Caldicott & Confidentiality Policy SH IG 42 Procedure for the Management of Personal Information All associated EPR Standard Operating Procedures and Service Specific Guidance Keywords (minimum of 5): (To assist Policy search engine) Records; Clinical ; health; documentation.

6 SH CP 221 Clinical Record Keeping Policy Version 4 March 2018 CLINICAL INFORMATION ASSURANCE STATEMENT The Trust is registered with the Care Quality Commission (CQC) which sets the standards of care

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