Record keeping is a fundamental part of professional practice. The purpose of this information is to provide record keeping guidance for the individual dietitian and other members of the dietetic team. It replaces the Joint BDA/Dietitians Board Guidance on Standards for Records and Record Keeping (2001).
The principles are applicable to all areas of practice. The guidance does not define a rigid framework, nor is it designed as an auditable standard; it aims to inform of key record keeping issues.
The British Dietetic Association (BDA) and Sports and Exercise Register (SENR) proudly represent the dietetic workforce, and accredited professionals within the speciality of sports and exercise nutrition, respectively. Registrants have a professional and legal obligation to keep an accurate record of their interaction with service users or clients.
This record keeping guidance is intended for use by all members of the BDA and SENR, who include registered dietitians, dietetic support workers/assistants, student members and sports nutritionists. These guidelines apply to all roles and settings in which they work.
This guidance document comes at a time when there is huge variability in terms of the use of paper or digital records across the profession. Therefore, has been written in such a way as to provide members of the BDA and SENR registrants with the principles that underpin good record keeping no matter what format their records are in or where they are employed.
This guidance is necessarily broad and cannot provide definitive answers to every situation a member/registrant may encounter. Nor does it provide a rigid framework for an auditable standard. It does however, provide the principles that will guide dietitians, the wider dietetic workforce and sports and exercise nutritionists in making, protecting and sharing of clinical records and any other personal data that they hold. These guidelines should be used alongside any record keeping guidelines set out by your employer.
Primary Purpose |
Secondary Purpose |
Underpin day-to-day service and delivery of care |
Assist in audit |
Help structure thoughts to aid decision-making |
Provide data for service development |
Be an accurate account of intervention and care planning |
Provide data for research |
Communicate between professionals |
Provide data for population monitoring |
Act to aid memory |
Provide evidence for claims complaints, inquests, inquiries, disciplinary hearings and other legal proceedings. |
Traditionally, health records have been thought of as having both primary and secondary purposes. As the digital world evolves around us, and service users increasingly expect data from their record to be used (anonymously) for service reporting and clinical research to enhance both the quality and diversity of service provision. The boundary between what is considered a primary and secondary purpose is becoming blurred.
Records are fundamental to safe and effective service provision.
All record keeping is governed by the European Union General Data Protection Regulations (GDPR).
Your duty to share information in line with GDPR, is as important as your duty to maintain patient confidentiality.
Being able to make and maintain records is a requirement of HCPC and SENR Code of Professional Conduct and all those who provide direct care are required to keep records. You have a duty to communicate fully and effectively with colleagues to ensure that they have all the necessary information to provide safe and effective care.
A health or care record is any record of information relating to someone’s physical or mental health that has been made by (or on behalf of) a health professional. Such records are extremely personal and sensitive.
A record is comprised of all data relating to an identifiable individual including but not limited to written records, emails, letters, diaries, photos, scans and monitoring charts. From paper to hard drives to the cloud, client data may be stored in a variety of platforms.
All personal data in the UK is governed by the 2018 Data Protection Act and EU General Data Protection Regulations (GDPR) 2018. There are 6 principles of the GDPR which must be adhered to. GDPR goes beyond the health care record and is applicable in all aspects of work where the processing of data that could personally identify an individual occurs.
Therefore, GDPR covers the whole business. For example, application would include but is not limited to personal data held as part of recruitment tasks, employment, running events and marketing services.
Principles of GDPR |
1. Processing should be lawful, fair and transparent |
2. Personal data shall be collected for specified, explicit and legitimate purposes |
3. Personal data must be adequate, relevant and limited to what is necessary |
4. Personal data shall be accurate and kept up to date |
5. Personal data shall be kept for no longer than is necessary |
6. There must be appropriate security in place in respect of the personal data |
The duty to share information can be as important as the duty to protect client confidentiality. You have a legal duty to disclose confidential information if there is risk of harm to the service user, yourself or others. This may mean sharing information without consent. If you work for the NHS you should discuss your scenario with your trust’s Caldicott guardian.