On 28 September 2020, CQC published interim guidance on what a good digital record system looks like and how providers can achieve this. CQC assesses digital records systems against the relevant Key Lines of Enquiry (“KLOEs”) and the characteristics of ratings, in the same way that paper records are assessed.
The guidance states that a good digital record system delivers good outcomes from the point of view of service users and that they are worded from a service user’s perspective using the following “I statements”:
I have records that:
- are person-centred. They describe what is important to me, including my needs, preferences and choices
- are accessible. I can see the information that is important to me, in a way that I choose, and I can understand
- are legible. Information about me is recorded clearly and can be easily read by the people who support me
- are accurate. Information about me is correct and does not contain errors
- are complete. There is no relevant or essential information about me that is missing
- are up to date. They contain the latest relevant and essential information about me
- are always available to the people who need to see them when they need them
- are secure. My privacy and confidentiality are protected. Only the people who should see my records can see them (records are kept in line with Data Protection legislation, including General Data Protection Regulation (GDPR) requirements)
- help the service that supports me to have good quality assurance systems and processes. They help the provider to assess, monitor and minimise the risks to my health, safety and wellbeing. They help the service that supports me to keep improving.
CQC’s Transitional Monitoring Approach and digital records
Under CQC’s new transitional approach to regulation, CQC states that inspectors will spend more time on virtual activity and less time on physical site visits and so inspectors may request more information from providers in a digital format. This includes inspectors asking for access to digital care records when not on site. Inspectors expect providers to provide log-in details to digital records and to support them in accessing any records that they need to see.
CQC is in the process of developing its next five-year strategy from 2021 onwards and has indicated that the interim guidance on digital records will be reviewed to reflect any new commitments made in CQC’s future strategy. A copy of CQC’s interim guidance on digital records can be accessed here.