TheatrePracticeStandardsGeneric1

Generic Theatre Standard No 02 - Operating Theatre Record Keeping
and Documentation at RCHT
Standard Statement: All staff are aware of the required standards for documentation and take
responsibility for all their individual documentation of information
Policy On Clinical Record Keeping on document
1. General Considerations
• Under the Public Records Act 1958 (National Archives, 2009), all NHS employees are
responsible for any records that they create or use in the course of their duties. Thus
any records created by an employee of the NHS are public records and may be subject
to both legal and professional obligations.
• The quality of record keeping is a reflection of the standard of professional practice
expected of professional practitioners (AfPP, 2007).
• The record must be (NMC, 2009):
• Factual, consistent and accurate
• Recorded/written as soon as possible after the event has occurred,
providing current information on the care and condition of the patient
• Recorded/written clearly and in such a manner that the text cannot be
erased, written in a manner that any alterations or additions are dated,
timed and signed such that the original can still be read clearly, with the
signature printed alongside the first entry
• Not include abbreviations, jargon, meaningless phrases, and irrelevant
speculation
• If written, recorded in black ink only so that photocopies are readable
• Records made in the operating theatre must adhere to the General Caldecott Principles
(HSC, 1998) on confidentiality:
• Justify the purpose(s)
• Don’t use patient-identifiable information unless it is absolutely necessary
• Use the minimum necessary patient identifiable information
• Access to patient-identifiable information should be on a strict need-toknow
basis
• Everyone with access to patient-identifiable information should be aware of
his or her responsibilities.
• Understand and comply with the law
Theatre Practice Standards - Generic
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