Section B7 of the CNHC Code: Maintaining client records
You must keep client records that are legible, attributable and truly represent your interaction with the client.
N.B. ‘Attributable’ means that it should be clear who has created, updated or amended a particular record.
The Code includes some useful guidance to help you understand what client records might include such as the client’s personal information, the client’s case history, their consent to assessment and care, and reassessment of their care or treatment plan.
Section B6 Providing access to client records, and Section B8 Safeguarding of client records, are also useful to check when thinking about how to keep client records.
Even if you feel very familiar with the Code, we recommend you review it regularly.
All CNHC Registrant will have been send a copy of our Code of Conduct, Ethics and Performance and you can also find it here.