A6: Managing personal information

• Their role in relation to record keeping: 

  • Ensuring timely, accurate records for every interaction and how they have provided care for the individual 
  • 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
• Their 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
• A6.2 Why personal information is collected, stored and protected:

  •  Collected: 
  • To obtain an individual’s history 
  • Diagnosis 
  • Treatment 
  • Follow on care 
  • Stored: 
  • So that it can be shared, as appropriate, with the wider network of multidisciplinary teams 
  • Future use 
  • Individual’s right to access data records 
  • Protected: 
  • Data protection regulations 
  • Information governance 
• A6.3 The types of information needed when obtaining a client history:

  • Name 
  • Date of birth 
  • Individual NHS or hospital number 
  • Presenting complaint 
  • History of presenting complaint 
  • Drug history 
  • Family history 
  • Social history
• A6.4 The purpose of common abbreviations used in the healthcare sector: 

  • Purpose of common abbreviations: 
  • facilitate and shorten written narratives 
  • standardisation 
  • Common abbreviations used: 
  • PRN - pro re nata (given as needed, for example medication) 
  • BP - blood pressure 
  • MAR - medical administration record 
  • DNR - do not resuscitate 
  • MUST - malnutrition universal screening tool 
  • NEWS - National Early Warning Score 
  • PEWS - Pediatrics Early Warning Score 
• • Advantages of reporting systems: 
  • Prevents misinterpretation of information 
  • Timely reporting information 
  • Easy access to patient/service user information for tracking or monitoring
• • When it is appropriate to share information: 
  • for the purpose of ensuring effective diagnosis, treatment and care of individuals 
  • for the purpose of sharing improvements to practice (for example as a result of research) 
  • for the purpose of sharing good practice
  • for the purpose of introducing new ways of working and innovations in practice
  • when there is risk of harm to individuals 
  • a crime has been committed or there is risk of it being committed 
  • safeguarding issues (for example suspected abuse) 
  • legislative requirements (for example the Care Act 2014) 
• Considerations when sharing data

  • Principles for protecting the individual's identification (for example Caldicott principles)
  • Using the individual's NHS number as identifier rather than the individual's name
  • Need to inform the individual and gain consent unless it is required by law to share or the benefit in sharing information outweighs keeping it confidential (for example safeguarding risks)
  • The individual's information and confidentiality requirements as set out in relevant regulations
  • Need to inform an appropriate adult or advocate if sharing the individual's information (for example where the age or mental capacity of the individual is an issue)
  • Intended audience (for example the individual or other health professionals)
  • Why information is being shared (for example to support the individual's care or to present outcomes of a project)
• 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
• Oral reports

  • To give immediate information to support an individual's care
• Written reports

  • Change of shift reports
  • Transfer reports
• Forms and documents

  • Referral form to Social Care Children's Services from a GP
• Presentations

  • To share good practice in a team meeting
  • Report of findings of a research project
• Graphs and tables

  • To summarise an individual's information
  • To summarise findings of a research project
• Leaflets or posters


  • To provide information about treatment options
• Web pages and social media

  • To provide information about health promotion initiatives
• Reasons for record keeping: 

  • to provide an overall view and history of the individual’s medical history and care needs (including all services accessed) 
  • provides access to an individual’s information for all multidisciplinary teams
  • continuity of care 
  •  to protect the individual and the healthcare and social care professional 
• How it contributes to the overall care of the individual: 

  • ensure uniform care is provided regardless of the service accessed ensures there is a record of what has been discussed and what took place within each interaction (for example next steps) 
• A6.9 The responsibilities of employees and employers in relation to record keeping and when to escalate issues: 

  • Responsibilities: 
  • legal requirements and inspections
  • duty of care
  • duty of candour 
  • investigation and tracking incidents and accidents 
  • accountability 
  • When to escalate:
  • safeguarding concerns
  • whistleblowing 
  • radicalisation concerns