Understanding clinical governance
Accurate and timely records are part of robust clinical governance. Everyone within a health and care organisation is responsible for managing records appropriately. It is therefore important that you understand how records should be managed appropriately. This includes how records are created, maintained, accessed and disposed of.
Clinical governance records
Clinical governance encompasses quality assurance, quality improvement and risk and incident management. Therefore, clinical governance records relate to those activities undertaken by NHS organisations to demonstrate accountability for continuously improving the quality of their services and safeguarding high standards of care.
Clinical intervention records
Clinical intervention records relate to the documentation of any professional activity intended to improve the use of medicines, which may result in a recommendation for a change in the patient’s medication therapy.
Patient safety incident records
Other record keeping resources
- Technical service records in hospital pharmacy
- Additional services records in community pharmacy
- Prescription and dispensing records in community pharmacy
- Retaining and storing pharmacy records in England
- Controlled Drugs records in pharmacy
- Stock handling, waste and recall records in pharmacy
- Prescription and dispensing records in hospital pharmacy
- Medicines information or advice records in hospital pharmacy
- Supply and distribution records in hospital pharmacy
- Miscellaneous records in hospital pharmacy
- Clinical trial records in hospital pharmacy
All record keeping resources
Record keeping
Update history
- Link updated for the Records Management Code of Practice (RMCoP).
- Published