Outcome 1 Understand the need for secure handling of information in health and social care
Identify the legislation that relates to the recording, storage and sharing of information in health and social care The Data Protection Act 1998 covers anything relating to a person, medical records, social service records, credit information, local authority information. There are eight enforceable principles:
Personal data shall be processed fairly and lawfully
Adequate, relevant and not excessive
Not kept for longer than necessary
Process in accordance with the data subject rights
Not transferred to countries without adequate protection
The Data protection Act also allows people to see information recorded about them through the Freedom of Information Act 2000, therefore people are allowed to see their social care files, this is important to know when entering information in people’s notes. The ICO Information Commissioner’s Office is responsible for upholding information rights in the public interest.
Explain why it is important to have secure systems for recording and storing information in a health and social care setting Information on Care homes and in house information is valuable and critical to the business of the home. This information must be stored and processed therefore it is essential that Information Security is maintained. The purpose of information security is to preserve:
Confidentiality data is only access by those with the right to see them. Integrity information can be relied upon to be accurate and process correctly. Availability information can be accessed when needed.
Insecure information can lead to violation of an individual’s human civil rights that may results in neglect/or physical, sexual, emotional or financial harm. Manual system of recording information has to secure so they are usually kept in a locked cabinet and may be in a secure room.
Know how to access support for handling information Describe how to access guidance, information and advice about handling information The first place to look for guidance and advice is the supervisor with regards to information in the work place. If you require information about a person, then that person’s care plan would be ideal. Information about legislation to ensure that you are complying with the law, them the Information Commissioner’s Office is the place to contact.
Explain what actions to be taken when there are concerns over the recording, storing or sharing of information If there is a concern relating to people’s records, the concern should be directed to the manager who is in the position to deal with the concern. For taking a concern further that has not being resolved, the concern needs to be : Put in writing
Be clear about dates, times and the exact nature of the concern Identify the steps that have already been taken and the response Involve trade union or professional organisation for support The steps for resolving concerns:
Discuss with line manager
Record the concerns and take it to a more senior manager
Take it to director or chief executive
Take it to the inspectorate
You are protected from unfair dismissal by an employer through the Public Interest Disclosure Act 1998 if your concern relates to the employer.
Be able to handle information in accordance with agreed ways of working Keep records that are up to date, complete, accurate and legible Records should provide objective, accurate, current, comprehensive and concise information concerning the condition and care of the client. The records kept should reflect an accurate and up to date picture of somebody’s situation. Records are kept to:
Provide a full assessment of the client’s needs
Provide record of any problems and the actions taken
Provide evidence of care required
Provide a baseline record against which improvement or deterioration may be judged
Records should le after be made as soon as possible after the event providing current information on the care and condition of the person.
Follow agreed ways of working for:
Good recording of information supports good practice in a number of ways. Supports effective partnership with users and carers, provides documented evidence and account of the department involvement with an individual, support risk assessment and risk management plans.
The principles for recording:-
Service users and carers are helped to understand the purpose and contents of their case record and are invited to contribute to it. Case records will be kept in accordance with Department of health guidance and legal requirements.
A care plan contains valuable information about a person in care and this information has to be stored. All documents are stored according to legal, organisational and ethical standards. Some information can be stored and displayed openly, i.e. menus can be stored in a kitchen. Documents, such as care plans, medication sheets, and employee files need to be stored in locked cupboards in locked rooms to deny access to those who have no right to the information.
Sharing information the home has a general duty in common law to safeguard the sensitive information they hold of individual’s. The home should have a clear policy on the Data Protection Act which staff should adhere to. It is important that staff should pay particular attention to ensuring consent to share information is clearly recorded on file. Where it has been necessary to share information without consent then the justification should be recorded and authorised by the line manager. There are different reasons for sharing personal information without consent:-
Court or tribunal orders
A person’s best interest
Risk to health
Protection to others
Partner agencies providing support.
It is important that you know the policies of the care organisation with regards to confidentiality and the disclosure of information in your workplace. The basic rule is that all information is confidential and cannot be shared with anyone without the consent of the person.