A6

• What is the healthcare professionals role in relation to record keeping?

  1. Timely and accurate
  2. Competent in using systems
  3. Confidentiality
  4. Information if factual
  5. Avoid abbreviations.
• What gets audited?

  Medication
• What are healthcare professionals role in relation to audits?

  1. Legible
  2. Date signed with signature
  3. Data being accurate
• What are some types of information is needed when obtaining client history?

  History of presenting complaints, Drug history, name, NHS number, Family history, date of birth, social history and presenting complaints
• Why is personal information collected?

  1. Treatment
  2. Diagnosis
  3. Obtain History
  4. Follow up care
• How is personal information protected

  1. GDPR DATA PROTECTION ACT
  2. INFOMATION GOVERNANCE
• Why is information stored?

  1. Right to access it
  2. Future Use
  3. Multi disciplinary team to access
• How does record keeping contribute to overall care of the individual?

  1. Protects health professionals and individual
  2. Obtain Overall view and history of individual
  3. MDT
  4. Continuity of Care
• What are the 2 purposes of common abbreviations?

  1. Standardisation
  2. Facilitate shorten written narratives.
• DNR – do not resuscitate

  MST – malnutrition screening tool

  NEWS 2 – National Early Warning Score

  PEWS – Paediatric Early Warning Score

  PRN – pro re nata (given as needed, for example medication)

  BP – blood pressure

  MAR – medical administration record
• Who regulates health and social settings?

  CQC
• What is the new framework called which the NHS introduced to report accident and incidents?

  Patient safety incidence response framework (PSIRF)
• Procedures and practices must be of the correct standard to pass the inspection. Failure to meet the expected standard can result in fines or closure
• Details of the incidentS must be recorded accurately so that an investigation can take place to identify how and why the incident happened.

  By having an investigation health professionals and the patient can find out what went wrong and what improvements / changes need to be made in the future
• A duty of care is a legal and professional obligation to safeguard others while they are in your care, using your services or are exposed to your activities. 
• Health professional’s have a duty to:

  • to safeguard individuals, promote their wellbeing and ensure that people are kept safe from abuse, harm or injury.

  •to escalate any safe guarding concerns.

  •to act if they believe that others are not upholding their duty of care
• A ‘record’ is any information about an individual​

  (a patient or service user) that is collected by being​

  written down or recorded electronically. 
• When do health professionals need to escalate concerns?

  1. When there is a safeguarding concern?
  2. When concerns need whistleblowing
  3. When there are radicalisation concerns
• MST- Malnurtition screening tool
• NEWS- National early warning score
• PEWS- Paediatric early warning score.
• Accountability is an acceptance of responsibility for honest and ethical conduct towards others.
• Whistle blowing is the procedure used when a health professional has really serious concerns about behaviour within their work place and they believe it is in the publics best interest to know about this.
• Radicalisation is defined as the process by which people come to support terrorism and extremism and, in some cases, to then

  participate in terrorist groups.
• What are the advantages of reporting systems:

  1. prevents misinterpretation of information
  2. timely reporting information
  3. easy access to patient/service user information for tracking or monitoring
• when it is appropriate to share information?

  1. for the purpose of ensuring effective diagnosis, treatment and care of individuals
  2. for the purpose of sharing improvements to practice (for example as a result of research)
  3. for the purpose of sharing good practice
• when it is appropriate to share information?

  1. for the purpose of introducing new ways of working and innovations in practice
  2. when there is risk of harm to individuals
  3. a crime has been committed or there is risk of it being committed
  4. safeguarding issues (for example suspected abuse)
  5. legislative requirements (for example the Care Act 2014)
• advantages of reporting systems:

  1. prevents misinterpretation of information
  2. timely reporting information
  3. easy access to patient/service user information for tracking or monitoring
• DATIX is the NHS reporting system
• Most health and social care settings will use standarised forms for the reporting of accidents, incidents and events. These can be either electronic or paper based. ​

  ​Using standarised forms  ensures that staff record only the relevant data.
• • All staff only record the information that is required in the correct format​
  • Only the necessary information is recorded​
  • Important information is not missed​
• Using standardized reporting systems for reporting and recording information:​

  ​

  • Ensures that information can be recorded quickly and more accurately​
  • Time is not wasted recording information that is not needed.  ​
  • Saves time when having to look back at information​
• Using standardized reporting systems for reporting and recording information:​

  ​

  • Easy to access the information that is needed (recorded and stored in a set way)​
  • Makes it easier to monitor a patient’s condition as each time the health professional is recording the same information​
  • Easier to track and monitor any changes in the patients condition​
• You must work on the presumption that every adult patient has the capacity to make decisions about the disclosure of their personal information. 
• • Emergency or life-threatening situations may warrant the sharing of relevant information with the relevant emergency services without consent.