Information Governance

Question 1

Purpose of Medical Record

Answer 1

• To document the patient’s problem to allow appropriate management decisions
• To form a baseline for future change in the patient’s condition
• To form a basis for communication to others involved in the patient’s health-care
• To form a basis for medico-legal evidence if appropriate
• To form a basis for research, teaching, audit and resource management
• Life long record held by GP

Question 2

CALT

Answer 2

A defensible record has to be Comprehensive, Accurate, Timely and Legible

Question 3

Good record keeping

Answer 3

• Promotes the best quality of patient care
• Helps to protect the highest standard of care
• Allows more effective monitoring of resources
• Helps in case of legal or disciplinary action
• Increasing use of information technology
• Increased litigation and Legal responsibilities

Question 4

Patients records should

Answer 4

• Be factual, consistent , accurate, relevant and useful
• Be written as soon as possible after an event occurred providing current information on care and condition of the patient
• Be written clearly and in such a manner that the text cannot be erased
• Be written in such a manner that any alterations are dated, timed and signed, so that the original entry can still be read
• Be accurately dated, timed and signed
• Be written, wherever possible, with involvement of the patient or carer
• Be clear, unambiguous, and written in terms that the patient can understand
• Identify problems and action taken to rectify them
• Provide evidence of the care planned, decisions made, care delivered and information shared
• Provide evidence of actions agreed with the patient (including consent to treatment and/or consent to share)

Question 5

Records should include

Answer 5

• Medical observations: examinations, tests, diagnoses, prognoses, prescriptions, other treatments
• Relevant disclosures by the patient – pertinent to understanding cause or effecting cure/treatment
• Facts presented to the patient
• Correspondence from the patient or other parties

Question 6

Records shouldn’t include

Answer 6

• Abbreviations, jargon, meaningless phrases, irrelevant speculation and offensive subjective statements
• Personal opinions regarding the patient

Question 7

Data Protection Act

Answer 7

1998

Question 8

Freedom of Information Act

Answer 8

2000

Question 9

Information Security Standards

Answer 9

2005 and IS Management NHS Code of Practice

Question 10

More

Answer 10

• The NHS Confidentiality Code of Practice
• The Records Management NHS Code of Practice
• Information Quality Assurance

Question 11

Caldecott Guidelines

Answer 11

• Justify the purpose of using confidential information
• Only use it when absolutely necessary
• Use the minimum required
• Allow access on a strict need-to-know basis
• Understand your responsibility
• Understand and comply with the law
• The duty to share information can be as important as the duty to protect patient confidentiality