Capturing data to show effective management of the service and its resources

There are some rules you must follow when you handle personal data. These are set out by GDPR and the National Data Guardian’s 10 data security standards. There’s a free toolkit you can use to help you meet them.

Using electronic records to capture assessments, diagnostics, care plans and interactions with a person and their family are now commonplace within health and social care services

Good quality records underpin safe, effective, compassionate, high-quality care. They communicate the right information clearly, to the right people, when they need it. They are an essential part of achieving good outcomes for people.

This guide clarifies what good digital records look like and how providers can achieve this. It also covers the commitments CQC makes to support providers’ use of digital record systems and what we will look at on inspection.