Medication Overview
Medication Overview
Last activity on October 22, 2024
Record Keeping and Completing Data
It is a requirement to keep clear and accurate records relevant to practice (electronic only, using either Pharmoutcomes in Pharmacy or My Client Genius in Primary or Secondary Care).
It includes all records that are relevant to your scope of practice.
You must:
- Complete all records at the time or as soon as possible after an event, recording if the notes are written sometime after the event on the system.
- Identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need.
- Complete all records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements.
- Attribute any entries you make to yourself, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation.
- Take all steps to make sure that all records are kept securely.
- Collect, treat and store all data appropriately under Data Protection, GDPR and Information Governance policies.
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