Handle Information in Health and Social Care Settings

Health and Social Care Level 2

Legislation

The law promotes the rights of individuals using health and social care services to confidentiality, information sharing, data protection and appropriate communication.

The Data Protection Act 1998 governs the storage and use of information collected by a wide range of organisations, not just those offering health or social care services. This law relates to personal information about individuals.

Some of the relevant aspects of the Act are as follows:

•The information should only be used for the purposes explained when it was collected

•The information should not be disclosed to anyone who has no right to see it

•The information collected should be relevant and contain no more than is necessary for its purpose

•The information should be accurate when collected and where necessary kept up to date

•Individuals should have access to the data held about them

•Appropriate security measures should be taken to prevent unauthorised access to data.

NHS Code of Practice 2003

The Confidentiality Code of Practice is a result of a major public consultation that included patients, carers and citizens, the NHS, other healthcare providers, professional bodies and regulators.

The Code offers detailed guidance on:

•Protecting confidential information

•Informing patients about uses of their personal information

•Offering patients appropriate choices about the uses of their personal information

•The circumstances in which confidential information may be used or disclosed.

Here is a good working definition of confidentiality from the document:

‘A duty of confidence arises when one person discloses information to another (eg patient to clinician) in circumstances where it is reasonable to expect that the information will be held in confidence.’

The Freedom of Information Act 2000/The Freedom of Information Act (Scotland) 2000

Anybody may request information from a public authority in England, Wales or Northern Ireland. This law relates to general information, not personal details. An example might be that a local authority is asked how many older people it is supporting through direct payments. The number may be disclosed, but not the names of the individuals who are supported.

It is important to know about the law and how to apply it in practice. The law does not say that information cannot be shared with anyone. Where there is a need to protect an individual it is important to share details with other practitioners.

If you are in doubt about what can be shared and who it can be shared with, ask a senior colleague.

Effective recording

TOP TIPS FOR EFFECTIVE RECORDING

•Records should be factual, consistent, objective, accurate and fit for purpose.

•Entries should be made as soon as possible after an activity has been performed or an event has occurred.

•If you are handwriting the records they should be written clearly, legibly, in black ink if possible and in such a manner that they cannot be erased.

•If you have to make any alterations or additions to a record it must be dated, timed and signed in such a way that the original entry can still be read clearly – do not use correction fluid – put a line through the work you want to change.

•Entries should be accurately dated, timed and signed, with the name of the person who wrote the record written clearly alongside the signature.

•Records should be written, if possible, with the involvement of the individual or their carer.

•Records should be clear, unambiguous, and concise. Any abbreviations used should follow common conventions. If the individual is involved, eg care planning, s/he must be able to understand what has been written.

•Individual’s records should not include unnecessary abbreviations or jargon, meaningless phrases, irrelevant speculation or offensive subjective statements, irrelevant personal opinions regarding the individual. Remember these are auditable documents.

•Electronic records follow the same rules as handwritten records and must be stored securely. Many systems will not allow amendments once they are written and accepted by the system.

Record keeping

Record keeping is a professional requirement of all social care practice and requires specific skills.

Failure to maintain records would cause considerable difficulties in respect of any legal proceedings e.g. allegations of negligence.

Information is essential to the delivery of high quality evidence-based social/health care on a day-to-day basis.

Records are a valuable resource because of the information they contain. This information can:

•Aid decision making

•improve care through clear communication of the reasons for and progress of care activities

•encourage a consistent approach to team working.

Without accurate, legible, clear, concise records which are regularly up-dated, easily accessible and stored confidentially, if appropriate, mistakes can be made.

Every person working in social care, who records, handles, stores, or otherwise comes across information, has a personal common law duty of confidence to comply with effective recording practice.

The Common Law Duty of Confidentiality

Common law is not written out in one document like an act of Parliament.

It is a form of law based on previous court cases decided by judges; hence, it is also referred to as ‘judge-made’ or case law.

The law is applied by reference to those previous cases, so common law is also said to be based on precedent.

The general position is that if information is given in circumstances where it is expected that a duty of confidence applies, that information cannot normally be disclosed without the information provider’s consent.

In practice, this means that all service user information, whether held on paper, computer, visually or audio recorded, or held in the memory of the professional, must not normally be disclosed without the consent of the individual.

It is irrelevant how old the individual is or what the state of their mental health is; the duty still applies.

Application:

•remember confidentiality is often broken outside the workplace – on the bus/train, in the pub

•don’t leave files on desk for anyone to read

•don’t share pass words for computers, keep them private

•don’t leave documents in the photocopier of fax machine

•personal accountability – need to attend training

•do not gossip

•store information securely

•do not allow unauthorised access

•do not give out information over the ‘phone without checking credentials

•ensure privacy when discussing sensitive information – remember curtains are not sound proof.

Questioning techniques

In order to find out information to write reports and make records we need to ask questions. We want to encourage openness so the individual will talk freely.

There are different types of questions that can be used. These include:

•Open questions: these encourage the individual to talk and allow them to say as much or as little as, they want to without feeling under pressure to answer in a certain way.

•Closed questions: these establish facts and narrow the context of the discussion. They are asked when trying to obtain very specific information or they are answered with yes or no. When asking closed questions the questioner controls the subject being asked and the focus of the answers.

•Probing questions: these follow both open and closed questions to obtain more information and more detail

•Leading questions: usually guide the response to one required by the questioner. These questions put pressure on the responder and discourage an individual response.

It is also important that we give individuals the feeling we are interested in them, otherwise they will not give us the information we require. Folded arms, little eye contact or being easily distracted can indicate that you are ‘closed’ rather than ‘open’ to what someone is expressing and not really interested.

Handling information

It is important to maintain the confidentiality and security of records and reports:

•To prevent personal information about individuals being disclosed to others who do not have a right or a need to know the information.

•Details of health issues such as HIV status being divulged could lead to the Individual being treated differently from others, or others not wanting to associate with them.

•Information could be passed onto other organisations such as those who sell health care products who might then pester the Individual to purchase their goods.

All individuals have a right to privacy and for personal information not to be shared unnecessarily.

•Care must be taken not to give out confidential information unnecessarily. Only the specific information required by an individual to meet the needs of the individual should be shared.

Guidance, information and advice should be sought from senior members of staff, training sessions and accessing the organisation’s policies and procedures concerned with records and record keeping.

Any concerns about the recording and storing processes for information should be shared with a senior staff member. You have a duty to protect the confidentiality of the individuals you care for. If you find confidential documents you must return them immediately to the secure storage point. If you hear others gossiping about individuals in your care it is best to diplomatically point out that this is breaching confidentiality.

It is important to remember that information should only be shared on a ‘need to know’ basis, so that the worker can carry out their role in the care team. This does not mean that s/he needs all the information on an individual, only the information that is required to support the individual appropriately.