Clinical governance and patient safety records in pharmacy

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Topics: Record keeping

Recommendations for the retention of clinical governance and incident records in all hospital pharmacy, community pharmacy and secure environment settings.

Understanding clinical governance

Accurate and timely records are part of robust clinical governance. Everyone within a health and care organisation is responsible for managing records appropriately. It is therefore important that you understand how records should be managed appropriately. This includes how records are created, maintained, accessed and disposed of.

Clinical governance records

Clinical governance encompasses quality assurance, quality improvement and risk and incident management. Therefore, clinical governance records relate to those activities undertaken by NHS organisations to demonstrate accountability for continuously improving the quality of their services and safeguarding high standards of care.

Clinical intervention records

Clinical intervention records relate to the documentation of any professional activity intended to improve the use of medicines, which may result in a recommendation for a change in the patient’s medication therapy.

Patient safety incident records

Other record keeping resources

All record keeping resources

Record keeping

Advice and guidance to support appropriate retention and storage of pharmacy-related records.

Update history

  1. Link updated for the Records Management Code of Practice (RMCoP).
  1. Published

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