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Biopsychosocial Health Essay

2554 words - 11 pages

Essence of Care


Benchmarks for Record Keeping

Document Purpose ROCR Ref: Title Author Publication Date Target Audience

Best Practice Guidance 0 Gateway Ref: 14641 0

ESSENCE OF CARE 2010 DEPARTMENT OF HEALTH 1ST OCTOBER 2010 PCT CEs, NHS Trust CEs, Care Trust CEs, Foundation Trust CEs , Directors of Nursing, Local Authority CEs, Directors of Adult SSs, PCT PEC Chairs, Special HA CEs, Allied Health Professionals, GPs, Communications Leads, Emergency Care Leads, Directors of Children's SSs, Universities UK, RCN, RCM, AHPF, SHA Lead Nurses, SHA AHP Leads, Patient Organisations

Circulation List

PCT CEs, NHS Trust CEs, Care Trust CEs, Foundation Trust CEs , Directors of ...view middle of the document... Mail, Telephone, Fax & E-mail TSO PO Box 29, Norwich, NR3 1GN Telephone orders/General enquiries: 0870 600 5522 Fax orders: 0870 600 5533 E-mail: Textphone 0870 240 3701 TSO@Blackwell and other Accredited Agents Customers can also order publications from: TSO Ireland 16 Arthur Street, Belfast BT1 4GD Tel 028 9023 8451 Fax 028 9023 5401

Published with the permission of the Department of Health on behalf of the Controller of Her Majesty’s Stationery Office. © Crown Copyright 2010 All rights reserved. Copyright in the typographical arrangement and design is vested in the Crown. Applications for reproduction should be made in writing to the Office of Public Sector Information, Information Policy Team, Kew, Richmond, Surrey, TW9 4DU. First published 2010 ISBN 978 0 11 322881 2 Printed in the United Kingdom for The Stationery Office. J002352911 cXX 09/10

Best Practice – General Indicators
Factor 1

4 9 10 12 13

Access to care records
Factor 2

Single records
Factor 3

Practice and evidence
Factor 4



Essence of Care 2010 Benchmarks for Record Keeping


Best Practice – General Indicators
The factors and indicators for each set of benchmarks focus on the specific needs, wants and preferences of people and carers. However, there are a number of general issues1 that must be considered with every factor. These are:

People’s experience
■■ People feel that care is delivered at all times with compassion and

empathy in a respectful and non-judgemental way ■■ The best interests of people are maintained throughout the assessment, planning, implementation, evaluation and revision of care and development of services ■■ A system for continuous improvement of quality of care is in place

Diversity and individual needs
■■ Ethnicity, religion, belief, culture, language, age, gender, physical,

sensory, sexual orientation, developmental, mental health, social and environmental needs are taken into account when diagnosing a health or social condition, assessing, planning, implementing, evaluating and revising care and providing equality of access to services

■■ The effectiveness of practice and care is continuously monitored and

improved as appropriate ■■ Practice and care are evidence-based, underpinned by research and supported by practice development

Consent and confidentiality
■■ Explicit or expressed valid consent is obtained and recorded prior to

sharing information or providing treatment or care


Also see Department of Health (2010) NHS Constitution The NHS belongs to us all. Department of Health: London accessed 07 May 2010 at dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113645.pdf


Essence of Care 2010 Benchmarks for Record Keeping

■■ People’s best interests are maintained where they lack the capacity to

make particular decisions.2 ■■ Confidentiality is...

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