Keeping records - guidance and checklist
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Why keeping records is necessary
Keeping records is a necessary and integral part of practice in health, social and community care, education and research.
It is an absolute requirement as part of a practitioner’s duty of care, and must be completed in line with relevant legislation, the standards of registration and professional bodies, and local policy.
Care records are legal documents and as such may be used as evidence in an enquiry or a court of law. Produced for occupational therapists working across the UK, this fourth edition has been updated to include information on the General Data Protection Regulation.
This guidance is an essential reference point in ensuring that occupational therapists keep care records that are fit for purpose and process them according to legislation.