Information Governance

Question 1

What is the principle source of healthcare data?

Answer 1

medical records

Question 2

What is the purpose of the medical record?

Answer 2

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 3

What should patient records be like?

Answer 3

Factual
consistent
accurate
relevant
useful
alterations can still be read

Question 4

When can medical records be shared?

Answer 4

only in the best interests of the patient and only with those who“need to know”

Question 5

What is information governance?

Answer 5

eries of best practice guidelines and principles of the Law to be followed by NHS/Social Care organisations and individuals

Question 6

What are the aims of information governance?

Answer 6

Holding information securely and confidentially
Obtaining information fairly and efficiently
Recording information accurately and reliably
Using information effectively and ethically
Sharing information appropriately and lawfully

Question 7

What are the organisational policies and procedures of information governance?

Answer 7

Do not share/disclose information without guidance from your line manager and the Information Governance Lead
Employees must report any breaches in confidentiality to the Information Governance Lead
Organisations are legally responsible but so are individuals within those organisations

Question 8

What are the confidentiality caldicott guidelines?

Answer 8

1) Justify the purpose of using confidential information
2) Only use it when absolutely necessary
3) Use the minimum required
4) Allow access on a strict need-to-know basis
5) Understand your responsibility
6) Understand and comply with the law