Recording of needs

Information and communication support needs must be recorded in a clear, unambiguous and consistent way either electronically or using paper records. It is important that the information is meaningful and can be acted upon.

Where electronic systems are used, technical details in the full AIS Guidance document should be referred to.

In electronic systems which use SNOMED CT, Read v2 or CTV3 codes, information must be recorded using the coded data items associated with the subsets defined by the Standard.

In electronic systems which use other coding systems or terminologies, or where paper records are used, such information MUST be recorded in line with the human readable definitions / categories associated with the data items.

It is the responsibility of the IT systems supplier or organisational lead to ensure that all electronic coding used is current and up-to-date.

In recording additional information about patients, service users, carers and parents, organisations should be mindful of their duties under the Data Protection Act 1998, including ensuring that information is ‘relevant’ and ‘not excessive’ (to the purpose of recording it).

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