We are reviewing our patient record policy and would be grateful for any information readers may have on 'process notes'. We define process notes as those notes that may be made, and held separately from the patient record, by a professional to help them understand their intentions with a patient/client.
The issues we seek information on are how, in the context of process notes, to:
ensure compliance with professional codes of conduct;
ensure that process notes support clinical supervision;
support the educational needs of students and the continuing professional education of qualified staff;
give advice on ensuring that 'all reasonable steps are taken to ensure that records over which professionals have control remain personally identifiable only as long as is necessary in the interest of those to whom they refer';
advise on destruction policy.
A related issue is those 'scraps' of paper notes that nurses and others make to support communication, particularly at handover times.
We are sure other trusts will have faced this issue and may even have constructed practical solutions. We would be most grateful to share information.
Martyn Fricker Director of Nursing West Herts Community Health trust 99 Waverley Road St Albans AL3 5TL