maind
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« on: September 30, 2012, 04:10:13 pm » |
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Hi Lyn! You may be responsible for completing all sorts of documentation, from medication administration records, accident reports, to care plans to daily records monitoring bowel habits, fluid intake and output or behavioural charts to name but a few. In your answer give examples of the records you fill in and explain when you fill them in and how (dated, timed and signed and with sufficient detail to allow others to understand what has happened during the course of your shift). It is good practice to give an example from your own practice - 'For example, I am key worker for Mrs X who takes medication 3 times a day and suffers from dementia. I fill in the medication records, initialling the sheets after I administer drugs (not signing before the person has taken them in case they decline) etc etc.'
Confidentiality is maintained in all sorts of ways - when you are updating records, never leave them lying around for others to read or steal the person's identity, never remain logged on to computerised records when you are away from the computer to prevent abuse of the system by others using your log-in details, never leave the computer screen on view to the general public. Paper records should be stored away in a locked cupboard when not being updated and the number of people with access to the keys should be limited. The locked cupboard should be within a lockable office. Computerised records must be password protected and each member of staff must have their own password.
Sharing information - always confirm the identity of the individual requesting the information and speak to your own line manager to handle the request through the correct channels. Ensure the individual consents to the information being shared and if they cannot give informed consent, it must be established who will advocate for the individual in case decisions like this need to be made. If consent has been established, it is then important to ensure that the system for transferring the information is safe. For example, faxing information may be risky as it is possible for the information to end up in the wrong hands - faxes should always be followed up with a phone call to ensure it has been received by the right person. Obviously, posting records carries similar risks. It may be that person to person transfer is the safest method to exchange hard copies of records.
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