Digital Record Keeping in Health and Social Care
Digital record keeping is quickly becoming the new standard in health and social care; in recent years, it has become paramount to upholding high-quality care in fast-paced environments.
As of July 2024, around 72% of CQC-registered social care providers had adopted digital social care records (DSCR) — a 14.6% increase from the previous year. Similarly, in the NHS, over 90% of hospitals are now operating with electronic health records (EHR), signalling a clear move away from traditional, paper-based systems for CQC compliance.
This article explores how embracing the shift to digital record keeping can help you enhance your regulatory compliance, improve your quality of care and help you work towards a safer and more coordinated service. Read on to learn how ClouDoc can support your business to modernise and streamline your record keeping services.
The benefits of digital record keeping
Paper-based records are increasingly viewed as outdated and prone to human error. They are typically more difficult to update, access, and share, all of which impact the quality and safety of care. Key advantages of digital systems include more coordinated and responsive care through real-time updates, secure sharing of information, and easier access across care teams.
For example, care plans can be reviewed, updated, and shared instantly with family members and key staff, fostering clear communication and promoting service users’ involvement, all while complying with UK data protection regulations like GDPR.
Supporting regulatory compliance
Another significant advantage of digitising records is enhancing regulatory compliance. Providers who are registered with regulatory bodies such as Ofsted and the Care Quality Commission (CQC) must ensure that their documentation meets the relevant standards and expectations, but managing this with paper-based systems can be time-consuming and inconsistent.
With ClouDoc, we help make this shift to digitisation easier. With our comprehensive document management system:
- All your policies and procedures are tailored to the regulatory requirements and securely stored in a cloud-based platform.
- Our document editor allows you to customise templates to suit your service.
- Our ‘My Documents’ feature makes it easy to upload or create files directly within the system.
- Built-in version control, time-stamped updates, and user activity logs also ensure a transparent audit trail, which can be essential for inspections or internal reviews.
- Professional plan subscribers can benefit from our DocuSign feature, which enables the digital distribution and signing of documents, improving communication with stakeholders and external professionals.
- Our newly introduced ‘Webforms’ feature enables clients to complete care forms online. With mandatory fields, checkboxes, and automated timestamps, webforms reduce the risk of missing critical information while enabling providers to track responses and monitor form status in real time.
Digital record keeping in safeguarding
In health and social care services, safeguarding is fundamental to ensuring the safety and well-being of service users. It is essential for care providers to have clear and accurate records to identify and respond promptly to potential safeguarding concerns.
Unlike paper records, which can be delayed, erroneous, or incomplete, digital systems ensure that concerns are logged immediately and stored securely. This improves communication across teams and helps to reduce the risk of critical information being overlooked.
In environments where staff work across multiple locations, digital records similarly allow for seamless handovers. Any staff member with appropriate access can review the latest safeguarding notes, track follow-up actions, and continue monitoring a situation. This continuity is especially important in supported living or domiciliary care settings, where the same staff may not be present at each visit.
Digitisation also facilitates better multi-agency communication. Files can be shared securely with social workers, safeguarding leads, and healthcare professionals, enabling faster coordination of care and ensuring that everyone involved has access to the most current information.
Audit trails are also essential for good safeguarding practices. They record who entered or amended each piece of information and when, which helps establish a clear timeline of events. In the event of an investigation, complaint, or inspection, these logs provide a reliable account of how safeguarding issues were identified, responded to, and managed.
Ready to go digital?
Digital record keeping is fast becoming an essential part of running a high-quality care service. It helps ensure regulatory compliance and offers service users and families more confidence and autonomy in their overall care.
Whether you’re just starting to explore digital options or are ready to upgrade your current system, ClouDoc can support your transition every step of the way. Reach out to our team at ClouDoc to book a free demo or learn more about how we can help you modernise your record keeping and improve the quality of care you provide.
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