In this essay I am going to write on issues of confidentiality and record keeping. Nurses are subject to ethical, legal and professional duties which are considered to be to respect patient’s confidentiality. I will discuss about a nursing home staff that turned up on the ward to collect some personal documents that belongs to a discharged patient from the ward. Griffith and Tengnah (2008) “states that maintaining confidentiality of patient’s information is a fundamental element of professional conduct and ethical practice for nurses”. The reason why I chose this incident is to explore the professional components of the incident that occurred during my clinical placement and to see how patient’s information can be maintained and the importance of record keeping. Patients’ information is identifiable because of their name, date of birth, address and postcode. A nurse must ensure that all confidential information obtained concerning patients must be protected and disclose only with patient’s consent (Rumbold, 2006).  In order to respect the staff name’s to confidentiality I will use a pseudonym to protect the patient and nursing home staff information (NMC, 2008). My pseudonym is Mr TC for the patient and Mr Anthony Adams. Pseudonymisation is a process that aims to provide a confidential solution to service users that are known to Trust (SLAM, Confidential Policy, 2010).


       I will discuss nursing professional issues of confidentiality and record keeping from different perspectives including nursing code of conduct, local Trust and national policies, common law applied to professional practice and ethics and other literature.

    Nurses have legal and professional responsibilities to respect the rights of patients and to treat them equally.  Patient’s records are to be kept confidential at all times. When a nurse accesses the patient records, the nurse is not to discuss the patient’s conditions or any other confidentiality information with anyone not assigned to care for the patient.  According to nursing and midwifery (NMC) code of conduct (2008) “states that nurses must respect patient’s right to confidentiality and must ensure patients are informed about how and why information is shared by those who will be providing their care”. South London and Maudsley (SLAM) NHS Foundation Trust “states that confidential information about patients can only be used for healthcare purposes and unless exceptional circumstances are present, can only be disclosed with the informed consent of patients. Where the patient lacks capacity and unable to consent, information should only be disclosed in the patient’s best interest”.  

    Nurses are to keep patients best interest in mind at all times, in order to avoid professional issues that could arise. Department of Health (DoH, 2003) “states that the duty of confidentiality arises when patient discloses information to clinicians in circumstances where it is reasonable to expect that the information will be held in confidence. Confidentiality is a legal obligation that is derived from case law rather than an Act of Parliament, built up over many years and often open to different interpretation. Confidentiality is also a requirement established within professional codes of conduct and there should be specific requirements within NHS employment contracts linked to disciplinary procedures. It is generally accepted that information provided by patients to the health professional, is provided in confidence and must be treated as such so long as it remains capable of identifying the individual it relates to. Once information is effectively anonymised it is no longer confidential”.        

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          The Data Protection Act 1998 tightened up access to disclosure to personal information by putting on the decisions of the individual nurses. SLAM (2010) “states that Data Protection Act 1998 is the legislation that provides a framework that governs the processing of information that identifies living individual-personal data in Data Protection terms. Processing includes holding, obtaining, recording, using and disclosing of information and the Act applies to all forms of media, including paper and images. It applies to confidential patient information but is far wider in its scope as it covers all staff records”. DoH ...

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