GP services for older people: a guide for care home managers
Managers' responsibilities and the NHS reforms - Accurate, up-to-date recording
Care home managers should ensure that accurate, up-to-date, consistent records are kept on medical conditions, health care and medications. Residents who wish to have access to their health records have a right in law to do so, with assistance if their capacity requires it, and may wish to make their own entries in the record.
The GP lists changes to medication on a professional log, and fills it in each time she visits. Then we issue prescriptions and then we would transfer them to service user administration records, and update the process. If she comes with the computer she can generate the prescription right after her visit – sent straight to the home. She has her own laptop and all the information is on there. It is pretty good.Care home manager 
Although the NHS publication 'Benchmarks for record keeping'  was developed to apply to NHS records, its person-focused approach and main principles are equally applicable to record-keeping in care home settings. In pursuit of the overall outcome that 'People benefit from records that promote communication and high quality care', three of the principles are:
- people are able to access their care records in a format that meets their needs
- people's care records demonstrate that their care follows evidence-based guidance
- people's care records are safeguarded and their confidentiality is respected.
Problems with record-keeping and sharing information reported by research participants, which can be associated with medication errors and other harm, include:
- hospital input (e.g. outpatient and discharge letters; changed medication) not recorded in care home or GP records, or inconsistent with such records) [24, 40]
- residents' records not available to GPs, hospital doctors or out of hours doctors when they visit care homes
- a lack of prescribing technology in care homes, meaning GPs have to return to the surgery to prescribe 
- residents entering hospital without an accurate record of their medications and preferences, such as their care plan. 
One study  found that prescribing and monitoring errors were linked to problems with records. Monitoring errors were associated with greater harm than other forms of error, and it was suggested that failure to monitor residents was linked to practice systems and software. It was difficult to establish the correct prescription, as there could be discrepancies between different medication records.
Quality improvement in record-keeping
Relatives in another study  suggested that homes should have a protocol for making sure residents never enter hospital without an accurate record of medications and care preferences, in line with any mandatory regulation. Managers in the SCIE Practice Survey, 2013 said they found that some professionals did not take the time to read basic information provided. There also needs to be a handover of resident information if a resident changes GP on entering a home.
Practice suggests that care homes should:
- keep records securely, while making them accessible to individual residents
- make sure that records are clear, complete, well written, up to date and consistent, with good visibility of key care plans, do not attempt resuscitation (DNAR) agreements and medication issues
- record hospital input – obtain discharge letters, etc., send on to GP to follow-up with post-diagnosis support and ongoing treatment/care
- make records available to hospital and out of hours doctors when they visit care homes, especially if the resident has recently moved into the home, has changed GP or been discharged from hospital
- investigate with GPs whether prescribing technology (e.g. mobile prescription tools – 'pods' – laptops and printers) could be provided for use in the care home, so that GPs do not have to return to the surgery to prescribe
- ensure that residents enter hospital with their care and medical plans, which should include their medications and preferences.
Participants in the SCIE Practice Survey, 2013 said that in some homes, GPs and nurses (including CPNs) regularly wrote medical information in the residents' notes or care plan. One participant described how, in her home, the GP made weekly visits and made notes of any consultation on a record system the home's nurses could access.
Other participants said they had learned to fax requests to GPs for referrals for secondary services, so as to have a paper trail if referral did not take place or was unduly delayed.
Internal and external information-sharing
It is recognised that some of the issues concerning external information-sharing, including with GPs and relatives, relate to the culture and behaviours of professionals in other agencies. However, accurate, up-to-date recording of information, and ensuring that the resident carries with them key significant information relating to their conditions and medications, are the responsibility of the care home and its manager.
Managers are best able to decide the most appropriate ways of sharing and updating information with staff. Care staff spend the majority of their time with residents and their observations, coupled with knowledge about a person's health needs and any resulting plan, are important. It is recommended that information about medical care, and medication in general, is made available, together with information about a resident's needs as they affect the person's health. This should be supported by training, supervision and role clarity.
All SCIE resources are free to download, however to access the following downloads you will need a free MySCIE account:
- Evidence review on partnership working between GPs, care home residents and care homes
- GP services for older people: a guide for care home managers
- Improving access to and experience of GP services for older people living in care homes: practice survey