4 Patient Care Record
1 A provider must, after consultation with each service user and, where it appears to the provider to be appropriate, any representative of the service user, as soon as reasonably practicable after the service user first received the service, prepare a Patient Care Record (“PCR”) which sets out how the service user’s health, safety and welfare needs are to be met.
2 A provider must ensure a record is made in the PCR, as closely as possible to the time of the relevant event, of the following matters:—
(a) the date and time of every consultation with, or examination of, the service user by a health care professional and the name of that health care professional;
(b) the outcome of that consultation or examination;
(c) details of every treatment provided to the service user including the place, date and time that treatment was provided and the name of the health care professional responsible for providing it; and
(d) every medicine ordered for the service user and the date and time at which it was administered or otherwise disposed of.
3 A provider must—
(a) make the PCR available to the service user and to any representative consulted under paragraph (1);
(b) ensure that the PCR is readily available to all health care staff involved in meeting the service user’s health and welfare needs; and
(c) where appropriate, and after consultation with the service user and, where it appears to the provider to be appropriate, any representative, revise the PCR.