Compliance UK

Clinical record-keeping audit

One of the 2 clinical records and sharps checks in Compliance UK's dental pack, with the fields to record, who usually does it and where it sits in the CQC framework.

What this check is

By default, Compliance UK schedules it once a year. You can change the schedule. The dentist usually does it.

The record is a document or certificate, added as a file or a photo.

Area
Clinical records and sharps
Default schedule
Every year
Usually done by
Dentist
Evidence kept
Document or certificate

Where it sits in the CQC framework

This check is evidence for 3 CQC quality statements.

Delivering evidence-based care and treatment · Effective

We plan and deliver people’s care and treatment with them, including what is important and matters to them. We do this in line with legislation and current evidence-based good practice and standards.

Monitoring and improving outcomes · Effective

We routinely monitor people’s care and treatment to continuously improve it. We ensure that outcomes are positive and consistent, and that they meet both clinical expectations and the expectations of people themselves.

Consent to care and treatment · Effective

We tell people about their rights around consent and respect these when we deliver person-centred care and treatment.

It also maps to Regulation 17: Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Other clinical records and sharps checks

Official sources