A6 - Managing Personal Information

• What is our role in relation to record-keeping?

  Ensuring timely, accurate records for every interaction and how you have provided care for the individual

  Ensuring you are competent in using systems to record data where applicable

  Ensuring confidentiality/security is not compromised by using unprotected data or by disclosing information in public places

  Ensuring the information recorded is factual and recorded in line with legislative requirements

  Avoiding abbreviations where possible
• What is our role in relation to audits?

  Ensuring 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 records accurately
• What are the types of information needed when obtaining a client history?


  Name

  Date of birth

  Individual NHS/hospital number

  Presenting complaint

  History of presenting complaint

  Drug history

  Family history

  Social history

  Social care involvement
• What is the purpose of common abbreviations?

  Facilitate and shorten written narratives

  Standardisation
• What are common abbreviations used?


  PRN - pro re nata (given as needed)

  BP - blood pressure

  MAR - medical administration record

  DNR - do not resuscitate

  MST - malnutrition screening tool

  NEWS 2 - National Early Warning Score

  PEWS - Paediatric Early Warning Score
• What are the advantages of reporting systems for managing information with regards to incidents, events and conditions?

  Prevents misinterpretation of information

  Timely reporting information

  Easy access to patient/service user information for tracking and monitoring
• When might it be appropriate to share information?

  Ensuring effective diagnosis, treatment and care of individuals

  Sharing improvements to practice

  Sharing good practice

  Introducing new ways of working and innovations in practice

  When there is a risk of harm to individuals

  When a crime has been committed or there is a risk of it being committed

  Safeguarding issues (e.g. suspected abuse)

  Legislative requirements (e.g. the Care Act 2014)
• What are the considerations when sharing data?

  Principles for protecting the individuals identification

  Using the individuals NHS number as an identifier rather than their name

  Informing the individual and gaining consent unless required by law to share or the benefits in sharing outweighs keeping it confidential

  Individuals information and confidentiality requirements as set out in relevant regulations

  Need to inform an approriate adult or advocate if sharing the individuals information (e.g. where age or mental capacity is an issue)

  Intended audience

  Why the information is being shared
• What are the different formats for sharing information?

  • Oral reports (e.g. giving info to support care)
  • Written reports (e.g. change of shift or transfer)
  • Forms and documents (e.g. referral forms)
  • Presentations (e.g. sharing good practice or report research findings)
  • Graphs and tables (e.g. summarise information or summarise research findings)
  • Leaflets or posters (e.g. provide treatment option info)
  • Web pages and social media (e.g. provide health promotion initiative info)
• What are the reasons for record-keeping?

  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

  Protect the individual and the health and social care professional
• How does record-keeping contribute to the overall care of the individual?

  Ensures 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 (e.g. next steps)
• What are the responsibilities of employees and employers in relation to record-keeping?


  Legal requirements and inspections

  Duty of care

  Duty of honesty

  Investigation and tracking incidents and accidents

  Accountability
• When would you escalate issues in relation to record-keeping?


  Safeguarding concerns

  Whistleblowing

  Radicalisation concerns