HCPC guidance set out in its Standards of conduct, performance and ethics states:
Keep accurate records
10.1 You must keep full, clear, and accurate records for everyone you care for, treat, or provide other services to.
10.2 You must complete all records promptly and as soon as possible after providing care, treatment or other services.
Following consultation with clinical directors and practitioners in both the private and public sector we took the view that the provision of shorthand symbols would not be in the best interests of our clients and their patients?
Why? Because your patients should be able to read their own notes without the aid of a healthcare professional and the use of shorthand symbols could potentially impede this fundamental right.
Additionally, GDPR also requires that data subjects should have full, unfettered access to their own data so that they know what information data controllers hold about them. The use of symbols in notes potentially breaches this right.
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