Queensland residential home allows service users to have an access to their personal information held by the data controllers, they have to request their information and the data controllers have the right to hide any information that is not relevant to them. However, if they want to see their medical records they have to contact their own GP’s for their records which they might have to pay minimum 50 amount of fees. Queenslands does not give permission to family members to look at their person’s personal file without their permission. Service users in Queenslands have the right to change any data that is incorrect or misleading. Moreover, if service users want to complain about the medical treatment they are receiving from that nursing home then they have the right to do so by requesting their medical records from personal GP’s.
James is Queenslands oldest service user; he has been in the home for more then 7 years. He is well aware of the system and rules that are kept by the care workers, however when his brother joined the nursing home he wasn’t aware of any rules set by the Data Protection Act so he decided to have a look at his brothers personal files because he thought he was allowed to do so as they were brothers. But the legislation explains that no one other then that service user is allowed to look at their personal files even if it their parents without their permission.
Health and social care practitioners have a duty to give service users information kept about them which can be accessing their medical records or explaining the procedures or even how to complain about the wrong information kept by the data controllers. The data controller’s responsibilities are to give service users access to their own information which can be from these legislation:
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Access to Personal Files Act 1987- This gives individuals the right to look at their personal information that are kept by data controllers.
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Access to Health Records Act 1990- This gives individuals the right to look at their NHS medical records which are kept by their own GP’s.
Personal information access rights
The Data Protection Act 1998 gives individuals the right to access the personal information you process about them. Individuals have the right to:
- know whether you, or someone else on your behalf, is processing personal information about them
- know what information is being processed, why it is being processed and who it may be disclosed to
- receive a copy of the personal information about them
- know about the sources of the information
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Access to Medical Records Act 1990:
The Access to Health Records Act 1990 is UK legislation which give service users right to access their medical records which are non-computerized or computerized. A health record means that a record which has information relating to individuals physical or mental health which is kept by health professionals which can be any of these following professionals such as:
- Doctor
- Dentist
- Optician
- Pharmaceutical chemist
- Nurse, midwife or health visitor.
- Dietician or a therapist
- Physiotherapist;
- Clinical psychologist, child psychotherapist or speech therapist
All service users in Queensland have a legal right to see their own Medical records that comes directly from the Data Protection Act 1998. Also, people who have the right over that service user such as the data controllers who can access their Medical records too. This Act explains who can see Medical records. That service users can see their own medical records which no one else can see without their permission. It is very important for the data controllers to take this legislation seriously so no one can see their medical records without their permission. Service users should be aware that they can access their records under the act of Freedom of Information which was applied in 2000.
There are two ways which service users are allowed to access their medical records. The first ways is a formal request made by the service user when they visit their GP, which they can receive a copy of their records, they can even make a separate appointment just to see their medical records. This request can be made by writing the request and returnin to their GP straight way. Another way to access medical records is to informal requesting their records which is made by the service user during a consultation. Under the Data Protection Act 1998, the following can have access to their medical records:
- Service user himself.
- A person who has authority to look at it on service users behalf.
- A person with parental responsibility when service user is a child.
- When the service user has passed awayhis personal representative.
“Under the Data Protection Act 1998, everyone has the right to access personal information held about themselves in either computerized or manual form. This relates to all existing records and includes NHS medical records and private healthcare records.”
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If a service user wants to see their medical records they will need to make a written request to their data holder such as their GP or their local hospital. Every care setting has a data controller who keeps every service users information private, to access the records the service users will have to show their ID first in order to access their medical records, and this may be such as filing in a special form to access their records.
The service user’s medical record will be saved on different place which means they might be save on a computer, nursing records or a chart. It is very important for them to be as specific as possible as to what they want to gain access to and make an appointment before they come to the doctor or a nurse.
The person who controls the records which is the data controller is suppose to give the service users his medical records within 40 days and should be available for only 21 days.
When a service user waits for 40 days there will be no fees on him however if he cant wait for the medical records then he will be charged and this can be up to £50 for medical records but for personal information held is only up to £10.
The Data Protection Act allows service users to get their personal or medical information corrected. If they are not happy with their information which might be misleading they can always request to change it and complain to the Data Protection Registrar.
Example of requesting medical records form:
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Misha from Queensland suffers from Parkinson’s disease which is a very severe illness making person forget things. Few years ago she fell very unwell and had to take some medications to make herself better, however when few months had passed, her condition went down hill meaning it became worse. Which then her family on her behalf requested her medical records from her GP, which was allowed. Nevertheless her family found out that they have been giving her the medicine at wrong times. Now Fawzia has decided that when they give her medicine they should ask her permission first.
Policies:
Policies come up when legislation is applied to any health and social care settings or any other settings which it is applied to; this makes sure all of these settings have the same advance to that duty or practice. By applying policies it will give them guide to what should be done to fulfil that task or who it should be done by such as cleaning for the cleaners only. Every organisation should have a number of policies which they should abide by no matter what to maintain quality and standard of care; this will help give good attention to the service users who need help. Policies are usually stored where care workers are mostly such as their areas. Policy can be anything such as:
- Confidentiality
- Moving and handling of items
- Accessing to personal files and records
- Health and safety issues
- Complaining about wrong care given
- Recruitments to right person
- Equal opportunity given to everyone
- Communicating with each other effectively.
Policies for confidentiality in care homes are very important as there are service users who like to keep to themselves without sharing information with people who are not authorised to know. All staff should meet the standards outlined in the Confidentiality so that no confidentiality of service users is broken unnecessarily. Where there is a service user who uses a computer to misuse the rights of service users by accessing their information and disclosing the password to someone else that might work in the care settings or might not. They can be subjected to disciplinary action and be prosecuted under the Computer Misuse Act 1990.
“The policy should encourage management, staff and volunteers to keep up to date with all relevant information and legislation.”
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Any care worker working in care settings have a legal duty to keep information about service users confidential. This means making sure that all service user’s information is practiced fairly and lawfully. Information that can recognize service users must not be used or disclosed for purposes other than medical conditions without that service user’s permission. An organisational confidentiality policy should clearly inform the prospect made of care workers in the following areas:
- Through a conversation
- When recording service users information
- When sharing their information
- When solving problems
- Breaking confidentiality
There are many times where care workers have to break the service users confidentiality without their permission. This is only allowed when there is a need and the care workers think that circumsatnce is exceptional, this can be when:
- Permission given by service users
- Permission given by the law
- Something is going to harm them or others
Procedure:
Procedure is when a task is carried out and how it should be carried out by the service users in a particular way. For example when there is a fire drill and all the service users have to exist from the fire exist door or when a service user makes a complaint, the procedure will tell them what exactly to do. There are many times when procedures are very important especially in care settings as there are many people who are weak and vulunerable.
When a service user makes a complaint because someone is trying to break their confidentiality they will have to follow a procedure where they will be direct best to who to tell and listen. They might be told to tell one of the senior care workers who might deal with complaints or they might have to fill in a form which might be available anywhere around the care home. This will guide the way they should do when they think someone might be breaking their confidentiality or try to break it.
Care workers might have a procedure of handling private information about service users which they will have to follow to keep the service users confidentiality safe. Some care workers might be told to task which other care workers might not do. They will follow a procedure which will guide them exactly how to deal with others confidentiality. There will also be a procedure to follow when care workers feel they need to break the service user’s confidentiality, they might be told to follow steps after they have broke the confidentiality after asking permission from the law.
Eliza is a care worker who works in Queensland Nursing Home; she deals with service user’s personal information. She makes sure she protects the service users confidential information so that she is not breaking the law, to do this she has to follow a procedure given by her manager which tells her exactly how to keep the information safe and out of reach of others.
Recording:
There will be many times in the care settings where the care workers will have to record information which they need apart from their personal details. The information that is record, care workers will have to make sure they record necessary information so that they are carrying out their duties and responsibilities properly. A care worker will have to know which one of the information of that service users is true and which one of it is their own opinion, and bearing in mind that only facts should be recorded because they are more accurate and legible then the service users opinions.
The Data Protection Acts tells the care workers exactly what t record and what not to record, anything they record will have to be related to that particular individual and no one else. The recorded information has to be legible so that it isn’t made up stories that the service user is telling them which is not related to that service user anyhow. Legible information means that is true that is a fact such as service user telling the care workers they have diabetes or lung cancer, the care workers will have to contact that service users GP for their medical records to see if it is true as there are many cases when service users lie.
When John in Queensland started new, he was told to fill out a form which it asked him to fill out his personal details such as home address or telephone number also telling him to fill out his medical form which had asked him if he has any kind of disease and he lied and wrote any disease that came to his mind just to get treated more then he was suppose to. When the care workers requested for his medical records from his GP, it had said that he only had diabetes, for this reason John was told off by the manager and they told him that if he ever gives unreliable data he will be reported to the police. This made John frightened a lot.
Also the information recorded by the care workers has to be accurate which means that any information that is inaccurate will not be accepted by the care workers, only precise data should be recorded such as when the care worker says that he has a cancer and does not state which type of cancer he has then the care workers will have to make sure they find out which type of cancer he has before they record the information down.
When Jane from Queensland started new she was told to state what disease she had so she wrote cancer without explaining further. This information the care workers wrote down as inaccurate as she did not state which cancer she had, so they contacted her local GP and asked and they told her that she had lung cancer from having cigarette seven times day which have nearly blocked her whole arteries.
Furthermore, the information that care workers record also have to be up to date because if the service users start to give in information that is not up to date then this will create problems for both care workers and service users. Care workers might still treat them with the same medication of their last illness of disease that they have. Also it is very important that the personal details that service users give out is up to date too.
Ben from Queensland moved houses so he had to change his phone number too, when he fell down on the stairs his leg broke while coming back home after seeing the GP, since he didn’t give in new information they was no way they could contact his family to tell them about the incident. For this reason it was very important for Ben to update his information with his GP in case of any emergencies that occur or even if they wanted to post out his health results they will send it to the old address and Ben might not be able to if his health is improving or not.
Information that is held by the care workers is very important that it is correct as any incorrect information will lead to wrong treatment given to that service user which will affect his health even more. There are two ways record could be written as which are:
- Written- such as letters, memo, reports, assessments, reviews or documents
- Electronic- such as emails, internet information, database or networking information
Care workers will have to make sure why they are recording records and who will be recording them, they will also have to bear in mind that whoever record the records has to be trustworthy person who will not disclose any personal information about that service user. Care workers have to make sure they record good amount of information as too little cannot be helpful and too much information might become confusing. When the records have finished, care worker should bear in mind that service users have to right to access them any reasonable time and correct any misleading information.
Sanjana is a care worker who record service users personal record and updates them every month. She makes sure she knows the reason as to why she is recording that information and how much information she needs to record so that it is not confusing ot very brief that will not help. Whenever she has finished recording information she makes sure she writes her name at the end to other care workers can now she has recording this information of that particular service user.
All written record should have a name of care worker who recorded the information written at the end of the page so he/she can be recognised. They will also have to write down the date too. This will help them know when they wrote this information so they can update it after a month, it will also others know that who wrote this so they can come to them and clarify it or if they cant read a word they can come to them and ask them what it says.
All computerised information has to accurate and up to date too as it is very important for care workers to do so. This can be service user’s personal home details such as their home address, telephone number or emergency numbers. If these are incorrect it can occur a lot of problems such as delay in treatments for example GP sending a letter to their house and that service user not receiving it as he doesn’t live there anymore.
Storage & Security:
Any information that is held by the care workers have to be stored in a safe and secure place where no unauthorised people can look at it without their permission. All the records must be protected so it prevents people with no rights to look at it. Also if a service user wants to see their records kept by their care home, care workers will manage to find it easily if it is set in a correct manner. There are two ways in which record can be kept these ways are:
- Manual- when the information is kept on a paper in a file which is stored in a filing cabinet or a filing system.
- Electronic- when the information is kept on a computer document.
Records that are kept manually should always be kept in a locker room for safety reasons so no unauthorised people can access to them. The key to the locker room should only be given to certain people who are trustable. The keys should be kept in a safe place where no one will be able to access it who doesn’t need to look at the personal details of service users for unnecessarily reasons such as stealing someone’s telephone number and disturbing them.
Every service user’s personal and medical records must be kept in a safe place which it will be protected so other people who don’t have the authority cannot look at it without care workers or that service user’s permission. The information which is collected about the service user should be kept in a cabinet or on a password protected file where no one will access to it. The password should be of which no one will be able to guess such as using this as a password: treehouse123.0, this is an example of a strong password. The care workers have to make sure they change the password every 3 weeks for security reasons so no one can hack into the files using hacking programs. The password which they protect the files with must not be given to anyone who is not authorized to look at the personal information about the service users. If any of the files are saved on the computer then the person who is control of record which is usually the data controllers must make sure that the records are protected with anti-virus protection program to avoid any hacking or viruses coming onto the computer as well as protects file not getting lost or broken.
The data controller’s have to make sure they have back ups for the records that are kept on the computer so that if there is a viruses on the computer at least the data controller will have file to back it up. It is their responsibility to make sure they also have back-up files of the patient’s records; back up files can be saved on floppy disk, USB sticks or even CD’s.
A data controller in Queensland Residential Home has the legal responsibility to make sure the files are protected from any misuse. It should able to safeguard any circumstance such as data loss, unauthorised access or any change that has been illegally done to the files.
Records that are kept on computer may also require the care workers to provide them with identity before they can access any personal records. Each person who has authority to look at that personal information about service users are given a password to prevent unauthorised entry into the protected file. It is possible that some care workers will be able access to more information then other care workers such as a dietician he will be able to access health records but will be restricted to personal records with the service user’s home address or telephone number.
Zahra who lives in Queensland nursing home will be able to access all her information because she will defiantly need to see her medical records to see if she is improving on her health or not which is very important as well as she needs to see Zahra’s address and telephone number so if she wants to make an appointment for Zahra she can contact her by telephone or send her a post to her given address.
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