QCF Diploma Health and Social Care

HANDLING INFORMATION

What we will look at:

• The legal framework• Confidentiality and sharing information• The importance of record-keeping

The Legal Framework

• It is important that workers in health and social care follow guidelines which are set in place to safeguard the rights and welfare of others. The legal framework is a term used to describe the process whereby policies. procedures and codes of practice are put in place to provide those guidelines in the workplace.

• The main law concerned with confidentiality and handling information is the Data Protection Act 1998.

The Data Protection Act 1998

• This law provides the basic principles on which personal information or data can be processed, and who has access to it. It covers paper-based records as well as computer files and other types of records.

• Data is defined in law as any information recorded in a structured filing system. In practical terms, it includes anything you record and store or pass onto others

• Processing includes systems used to organise. use and access the information. It includes collecting, using,keeping,sharing and destroying data.

Main Points of the Law

• All record systems must be registered.• Data held must be fairly and lawfully processed.• Data held must be adequate, relevant and not excessive.• Data must be kept secure.• Access to the information is limited to authorised personnel.• Employees have a duty to keep confidential information

safe.• Data should not be kept for longer than is necessary.• Data held must be accurate.• Data must not be sent to other countries without

appropriate protection.

Access to Health Records Act 1990

• This Act has been largely replaced with the Data Protection Act

• 1998.The only part of the Act that is still in force gives rights of

• access to a person who may be entitled to bring a claim of negligence over an individual's death to see their records.

The Caldicott Report 1998

• The Caldicott Committee was set up to examine patient information in the NHS and make recommendations as to how it should be handled. In 1997, the recommendations were published. They apply to hospitals and all NHS organisations, but they are relevant guidelines to follow in any care setting.

The Caldicott Principles• The Caldicott Report principles are as follows:• Justify and constantly review the purpose of keeping particular information.• Patient-identifiable information should only be used if there is no alternative.• The minimum amount of identifiable information should be recorded.• Access to patient-identifiable information should be restricted. Access should

only be given where essential and only the essential sections of information should be released.

• All staff should understand their responsibilities relating to confidential patient information.

• All use of patient-identifiable information should be in line with legal requirements.

• Information refers to all records held which may be contained in paper files, computer records,tape recordings, photographs or on video.

Activity

• The Caldicott principles are about information that is 'patient identifiable'. The same principles apply to health and social care, where information can reveal an individual's identity to other people apart from the care team, for example names on doors. This sort of information could be present in many forms within any care setting.

• Give examples of how personal details or information may unintentionally reveal the identity of an individual.

Answers could include:

• Addresses.• Personal details that may make them identifiable, such as

their particular circumstances (for example, an unusual condition or home situation). This is especially applicable within small close communities or with famous or well-known people.

• Photographs, which are used to identify individuals on the care plan, or taken for brochures, must be used for their purpose only and with consent.

• Acknowledging patients, their relatives or friends, as in the context that you know them in front of other people outside the health-care setting.

Confidentiality and Information Sharing

• Everyone has a right to have their personal details kept confidential. When people give information about themselves, they don't expect it to be passed on to anyone unless they are involved in their care or treatment. If you fail to handle information carefully and sensitively, there can be damaging consequences, such as service users staff losing trust and respect for you.

Information

• This refers to all records held, medical forms, photographs, etc. People receiving care give their consent for information to be shared with those involved in their treatment and care. This doesn't mean that everyone has access to their medical notes, for instance, but that they are given only information relevant for them to carry out their role.

Thinking point!!!

• In everyday life, people choose which personal details they share with others. They decide how they want to be seen by others and are able to control this. There are different situations within health and social care where it is not possible - imagine how people must feel in these circumstances.

Policies and Procedures

• All ser vice providers have a confidentiality policy that sets out worker responsibilities when sharing information. These responsibilities include:

• No unauthorised use of information that you have access to through work.

• The importance of obtaining individuals' consent for sharing information.

• How to prevent careless breaches of confidential information within or outside the workplace.

• Ways of checking identity and authorisation before giving information to people who request it.

Principles of Confidentiality• You should not share information about an individual with anyone

at work unless they are authorised to access it.• You must never discuss sensitive information outside work.• When you are asked to share information with someone• other than the immediate team, you must ask for permission from

the individual concerned.• Maintaining confidentiality builds trust between you and those you

provide a service for and work with.• Individuals have a right to see their records if they wish.• You should be sure of someone's identity before giving information.

Activity

• How would you keep information secure in the following instances?

• Having a face to face conversation• On the telephone

Good practice

• All confidential data and information in whatever format should be kept out of sight of others in the household. kept securely during transport and not left in cars overnight.

• Personal data about individuals stored on mobile devices should be encrypted.

• Sensitive information should be marked 'confidential' and kept in appropriate packaging.

• If the workplace allows data storage equipment and information to be removed from the premises. check with the supervisor for guidance on your responsibilities. The organisation will have a policy to deal with this.

Authorisation and Proof of Identity

• When you do give any information to other people you have to make sure that they are authorised to access it.

• This means that you must be satisfied with the identity of the person.

• In some organisations staff wear a photo-identity card which is visible and visitors are given a badge.

• If you are not sure you can approach them for further information or check with another staff member. Remember that genuine visitors should be pleased that staff work hard to protect security and confidentiality.

Activity

• Give examples of situations where people might think they have a right to ask you for information about others. How can you refuse to give information?

Breaching confidentiality - your responsibilities

• There are some situations where you would need to break someone's confidence and pass on the information. These are:

• If the person intends to harm themselves.• If the person is at risk of causing harm to others.• If the individual's health is at risk.• If there is an indication that a serious crime has been or is

about to be committed.• If you receive information about child abuse. you have a

duty to pass on this information whether or not the child agrees.

Activity

• List down some of the records you keep in your workplace? Where are they kept and why are they important.

The Importance of Record Keeping

• Record-keeping is important in any working environment and a health and social care setting is no exception. You are responsible for your actions, and good recording will help support you if ever you have to explain, or account for, your actions or incidents that happened to you

The Importance of Record Keeping

• One of the advantages of written information is that you have a permanent record that can be kept for a long period of time. This is particularly important in health and social care if information is misunderstood, not shared or 'forgotten' there could be serious consequences.

• In many cases it is a legal requirement to complete records, for example, accident reporting. It is important to be aware that these records could be needed in a court of law. All entries should be legible, accurate and make sense.

• Staff need to share information to ensure the smooth running of the service and records provide another form of communication.

• Many records are for the purpose of health and safety, such as risk assessments. Others help with monitoring the environment such as a visitors book or records used to monitor the fridge temperature.

Thinking Point!!!!

• There is a saying, 'If you didn't write it down, it didn't happen'. This helps to emphasise the fact that your records provide evidence of your work activities and any events that happen during that time.

• When you complete records, you are accountable, or take responsibility for, the actions and details you record. Always read through what you have written- if you can't make sense of it, neither will anyone else

How to report and write records• Clear and legible - easily read by others.• In the correct format - using the documentation provided.• Timely- written as soon after the event as possible.• Concise and to the point.• Complete - includes all relevant information.• Contains facts, not opinions.• Permanent - using black ink.• Tamperproof - no changes made since the original record was made.• Written in appropriate language - respectful. appropriate to the

situation and the working environment and avoid the use of acronyms.• Signed and dated as indicated.

Sharing the Right Amount of Information

• Written information can provide a permanent record of the communication, but is not always required to do this. It can be a way of communicating information and reaching a wider audience as it can be copied and circulated.

• Most of the principles of keeping good records are as important when sharing information in this way with other people.

The Right amount of Information

• If you are asked for information, you have to make a decision about the amount of information you should give without revealing personal or private details. You are given guidance about this, which is set out in the organisation's policies and procedures. In health and social care. confidentiality is an important factor influencing how much information you should share, and who you can share it with. You have to balance the need to protect personal information with making sure enough details are provided.

Summary• When you complete records, you are accountable, or take

responsibility for, the actions and details you record.• When asked for information by someone other than the immediate

team, you can only provide it with the consent of the person it involves.

• If you are careless with confidential information, you let down yourself. the person it involves the organisation you work for and your profession.

• Always read it through after you have made an entry into records- if you can't make sense of it. neither will anyone else.

• Information should be presented according to the requirements of the organisation, usually set out in their policies and procedures.

Well done!!!!

• You have now completed your Mandatory Units…