A6 - Managing Personal Information Flashcards
What steps can we take when information is not stored securely?
- Secure the information where possible
- Record and report the incident to the designated person, following organisational policies and procedures
What is an individual’s role in relation to record keeping?
- Ensuring timely, accurate records for every interaction and how they have provided care for the service user.
- Ensure they are competent in using systems to record data where applicable.
- Ensure confidentiality/security is not compromised by leaving records in public places or data is unprotected
- Ensure the information recorded is factual and recorded in line with legislative requirements
- Avoid abbreviations where possible
What is an individual’s role in relation to audits?
- Ensure information is legible where records have been recorded by hand using black ball point pen
- Ensure all records have a date, time and signature
- If using systems ensure care is taken to enter data record accurately.
Why is personal information collected?
To obtain an individual’s history, diagnosis, treatments and follow on care
Why is personal information stored?
So that it can be shared, as appropriate, with the wider network of multidisciplinary teams
Why is personal data protected?
- Data protection regulations
- Information governance
What types of information are needed when obtaining client history?
- Name
- DOB
- Individual NHS/Hospital number
- Presenting complaint/History of presenting complaint
- Drug history
- Family history
- Social history
What is the purpose of common abbreviations in the NHS?
- Facilitate and shorten written narratives
- Standardisation
What are the advantages of reporting systems for managing information regarding incidents, events and conditions?
- Prevents misinterpretation of information
- Timely reporting information
- Easy access to patient/service user information for tracking or monitoring
When is it appropriate to share information?
- Ensuring effective diagnosis, treatment and care of individuals
- Sharing good practice
- Introducing new ways of working and innovations in practice
- Risk of harm to individuals
- A crime has been committed
- Safeguarding issues
- Legislative requirements
What considerations should you make when sharing information?
- Principles for protecting the individual’s identification
- Using the individuals NHS number instead of their name
- Need to inform the individual and gain consent unless it is required by law to share the information
- Why information is being shared
What are the different formats for the sharing of information?
- Oral reports
- Written reports
- Forms and documents
- Presentations
- Graphs and tables
- Leaflets or posters
- Web pages and social media
What are the reasons for record keeping?
- To provide an overall view and history of the individual’s information for all multidisciplinary teams
- Continuity of care
- To protect the individual and the healthcare professional
How does record keeping contribute to the overall care of the individual?
Ensure uniform care is provided regardless of the service that is accessed ensures that there is a record of what has been discussed and what has taken place.
What are the responsibilities of employees and employers in relation to record keeping?
- Legal requirements and inspections
- Duty of care
- Duty of candour
- Investigation and tracking
- Incidents and accidents
- Accountability
