Publish date: 2 August 2023
If staff discuss patient care within an email, then this information must be uploaded to the EPR (Electronic Patient Record).
Record Keeping Policy Guidance
Please do not copy and paste entire email trails and documents into progress notes or clinical entries in the EPRs.
If an email or other document is pertinent to the patient’s record, it must be saved and uploaded as a document into the EPR and then a reference made in the clinical entry.
In RiO, the email/document must then be associated to the progress note.
Key Points
- Patient names must not be used within the email – the NHS Number is the unique identifier and should be used for this purpose
- Staff should also be aware that an uploaded email forms part of the EPR and is therefore accessible to the patient should they request access to their records
- Care should be taken when recording information within the email to ensure the information is accurate, in plain English and without the use of jargon or abbreviations.