Record keeping It is important to keep comprehensive and well-maintained records of all complaints received, investigated and responded to. These will be particularly important if a complaint is referred to another public body such as the Ombudsman.
A complaint file has the same status as a healthcare file and should be treated as such. It is a public record and its contents must remain confidential. Orderly complaints records3
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quick retrieval and review of details confidentiality adequate audit trail decisions can be reconfirmed or reconsidered at a later date efficient means of complaints analysis to improve services organisational transparency ability to meet obligations under access to records legislation.
Complaint files should be maintained and updated by a designated complaints officer or manager and kept separate from health records. The Healthcare Commission has recommended that files should include: •
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ensure:
a summary sheet recording date and description of significant events in the management of the complaint a full and legible copy of the relevant sections of the clinical records copies of any earlier clinical records that may be relevant to the complaint all written correspondence related to the complaint notes of telephone calls or other conversations relating to the complaint report of the investigation into the complaint notes from meetings relating to the complaint summary of any action taken in response to the complaint and/or evidence of changes made as a direct consequence of the complaint. 3
In England, practices are required to supply the PCT an annual report detailing the number of complaints received and upheld and those referred to the PHSO. It should also include a summary of the main reasons for complaints, lessons learned and actions taken to improve the service as a result.
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