- Reveal personal information concerning somebody else.
- Be likely to cause serious harm to the physical or mental health of the subject.
- Reveal the identity of others (not including care professionals) who have provided information in confidence and who have not consented to it or their identity being disclosed.
Care Standards Act –
The Care Standards Act 2000 (CSA) came into force on April 1, 2002. The Act is an updating and reforming of The Registered Homes Act. Its objective is to enhance the safety and protection of those in care.
Care services included in the CSA are:
- Residential care homes
- Nursing homes
- Children's homes
- Domiciliary care agencies
- Fostering agencies
- Voluntary adoption agencies
(including private hospitals and clinics and private primary care premises)
Each care service must adhere to a number of minimum standards. The core minimum standards are common to all care services. A number of additional minimum standards are related to particular types of services. The core standards include:
- Information provision – service users should receive clear and accurate information about their treatment and its likely costs.
- Quality of treatment and care – the treatment and care provided must be service user centred.
- Management and personnel – service users are assured that the establishment is run by a fit person / organisation and that there is a clear line of accountability for the delivery of services; Service users receive care from appropriately recruited, trained and qualified staff; Service users are treated by healthcare professionals who comply with their professional codes of practice; Children receiving treatment are protected effectively from abuse.
- Complaints management – service users have access to an effective complaints procedure; Service users receive appropriate information about how to make a complaint; Personnel are freely able to express concerns about questionable or poor practice.
- Premises, facilities and equipment – Service users receive treatment in premises that are safe and appropriate for that treatment; Service users receive treatment using equipment and supplies that are safe and in good condition; Service users receive appropriate catering services.
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Risk management procedures - Service users, staff and anyone visiting the registered premises are assured that all risks connected with the establishment, treatment and services are identified, assessed and managed appropriately; The appropriate health and safety measures are in place; Measures are in place to ensure the safe management and secure handling of medicines;
- Medicines, dressings and medical gases are handled in a safe and secure manner; Controlled drugs are stored, administered and destroyed appropriately.
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Records and information management - Records are created, maintained and stored to standards which meet legal and regulatory compliance and professional practice recommendations; Service users are assured of appropriately completed health records; Service users are assured that all information is managed within the regulated body to ensure service user confidentiality.
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Research - Any research conducted in the establishment/agency is carried out with appropriate consent and authorisation from any service users involved, in line with published guidance on the conduct of research projects.
Access to Personal Files Act –
The Access to Personal Files Act 1987 is the statute that covers the right to access records held by the housing and the social services. Service users that apply must be allowed to see their records, although, as mentioned above, there are certain types of information that may be withheld from them. They can only see information about themselves, and information may be kept back if it would harm the applicants or someone else’s physical or mental health.
Ideally, health and social care professionals would disclose all relevant information to service users and keep them informed about all matters relating to their care or treatment. It should not really be necessary for service users to have to make a formal application to see their records. They can be granted access informally. As there are relatively few formal applications to see health and other personal care files, it maybe that this is what occurs in practice.
IMPACT OF LEGISLATION: -
The fact that the law is making records more available to the public could cause many problems. The greatest fear is the security issues of confidential information being kept and its accessibility, which may be open to abuse. Computerised information is not as secure as written documents kept under lock and key. However, the service user can experience confidence and trust in the system that is there to care and protect by being allowed to access information regarding themselves.
Premises that house elderly and infirm people, people with physical disabilities and/or mental disorders who require care must be registered and regulated by law to protect these vulnerable individuals. It is important to ensure that high standards are maintained.
Legislations are set, initially to protect ‘the people’, when problems and holes are found in such legislation, amendments can be made. No regulatory system can absolutely guarantee consistently good standards everywhere, but they make sure that the system in place does everything that is possible to prevent and root out the abuse and neglect of vulnerable people.
TYPES OF RECORDS:
There are several different types of records that need to be filled out by health and social care practitioners for several different reasons.
Admission records contain lots of current information about the service user that is necessary to know so that he can be treat accordingly, and highlights of previous medical problems that may shed light upon the current situation.
Admission records must contain the following;
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Name; to distinguish the person in question. Use forenames, middle names or initials, and surnames in case there are two people with the same name. Keep service users tagged and check that you are treating the correct person always. Call service users by their chosen name to be informal.
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Age; gives an idea of the service users general health. Certain conditions are age related. Will also distinguish the service user from somebody else with perhaps the same or similar name.
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D.O.B; useful for drug checks to ensure drugs are being administered to the correct service user.
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Address; this may also distinguish the service user. Where the service user lives may be relevant to their condition.
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Telephone number; in case they need to be contacted after care.
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Marital status; to find out if there is a relevant somebody that is to be contacted in case of emergency. May also be relevant to know if the service user will have somebody to care for him or her at home.
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Religion; in case there are any special dietary requirements or beliefs that may affect their treatment.
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Next of kin; to find out who the service user wishes you to contact on their behalf in case of emergency.
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Next of kin relationship to the service user; to determine the relationship between service user and next of kin
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Next of kin telephone number; to contact in an emergency.
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Next of kin address; to know how far away they are in case of after care, support etc. In case they cannot be contacted over the phone, it may be necessary to go to their address in case of emergency.
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Contact in an emergency; in case the next of kin is unavailable.
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G.P; helps to access relevant information and assists the G.P with follow-up care.
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G.P’s address; so notes etc can be forwarded to the G.P
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G.P’s telephone number; so the G.P can be contacted.
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Lives alone yes/no; relevant to know if the service user will have somebody to care for him or her at home.
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Discharge/transfer; to locate the service user after care if necessary.
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Room; where they are located in the hospital. Makes service user accessible to the carer.
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Permanent/temporary; to know whether service user is in for long or short term. Helps carer build up the relationship needed with the service user. More in-depth information is needed for long stay service users.
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Date /time admitted; to know when the service user was admitted.
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Type of admission; acute/emergency or planned? Gives carer an idea of the type of care needed.
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Reason for admission; Gives carer an idea of the type of care needed.
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Confirmed diagnosis; affects type of care given. Gives information on medical condition.
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Service user aware of reason for admission; service user needs to be aware of his or her situation. To evaluate the service users awareness of the circumstances.
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Urinalysis; to eliminate any possible conditions.
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Weight; excessively over or under weight causes health problems. Need to rule out all possibilities.
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Past medical history; to assess and rule out all possibilities.
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Allergies; so that foods and medications that cause a reaction can be avoided.
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Investigations; previous tests and results, so as not to carry out the same tests over again, to reduce time wasting.
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Dates of investigations; to assess whether and if so when they need doing again.
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Vision; if the service user has poor vision this will need to be considered when giving reading materials, prescriptions, medication etc.
A daily statement of service users’ health is a daily record that monitors the progress of the service user and informs other carers of any change.
Monitoring should be repeated throughout care so adaptations can be implemented to suit any changes in condition. A variety of sources of information can be used to monitor, for example: service user interview, service user records, observation of service user, their care, and environment.
Assessment records feature the observation of:
- Physical condition, behaviour and personal circumstances.
- Questioning.
- Use of secondary sources including: medical records, relatives, advocates, support networks.
Progress reports are to obtain feedback on the service users’ current condition; this will assist in the future care plan.
The care plan states the service users’ problem and the expected outcome, the care that will be given and a time scale for reaching the objective or to review the service users’ condition. The service user and carer will work together on the care plan. Care plans are reviewed at set times as the care needed may change; the care plan should be altered accordingly.
The Visitors log should consist of the visitors name and the time they entered the care setting, and whom they are visiting. Their car registration number is also necessary in case their car needs moving. Visitors need to sign in and out because of fire regulations.
Accidents should be recorded in the accident book however minor. All employees should have a sound knowledge of the arrangements for getting first aid. Employees must inform their employer verbally or in writing as soon as possible of any accidents, sickness that may have been caused by work, dangerous occurrences and ‘near misses’. Near misses must be reported because this could help to identify potential risks and prevent them occurring in the future.
Incident forms must always be filled out too. They can highlight flaws in security. Incident forms are for something you can’t account for like the ‘near misses’ for example.
PURPOSE OF RECORDS:
All records that are kept are important written documents that could be used in court. It is therefore crucial that they are legible, clearly stated, accurate, signed and dated by the carer.
Records need to be clear and accurate so other professionals can read them too so the best care possible can be provided.
We need records:
- To provide personal details and previous medical history
- To capture initial service user information at time of referral
- To record the initial assessment and diagnosis of the service user's condition
- To form a basis for planning the service user's care and treatment, getting feedback on their progress and suggesting action for prevention and health promotion
- To assist continuity of care amongst health professionals and provide written evidence that a service has been delivered
- To meet legal requirements
- For security
- For health and safety
Poor record keeping:
- Undermines service user care
- Makes health professionals vulnerable to legal and professional problems
- Increases workloads
BIBLIOGRAPHY
Data Protection Act 1998 information was taken from –
Heinemann AVCE Advanced Health and Social Care (2000)
3rd Edition
Registered Homes Act information was taken from –
Care Standards Act information was taken from –