Question to the Department of Health and Social Care:
To ask the Secretary of State for Health and Social Care, what guidance his Department has issued on which people are authorised to make notes on a patient's medical record.
In 2016, the Information Governance Alliance published the NHS Records Management Code of Practice which sets out what people working with, or in, National Health Service organisations in England need to do to manage records correctly.
The Code of Practice is based on current legal requirements and professional best practice. It includes advice that each NHS organisation should have an overall policy statement on how it manages all its records, including electronic records.
It is the responsibility of each NHS organisation to ensure that staff are assigned access to patient records based on their role in the organisation and that, where appropriate, they should document their actions and decisions in patients’ records.