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where I get advice and guidance regarding handling information?

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Author Topic: where I get advice and guidance regarding handling information?  (Read 4364 times)
lyn2col
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« on: September 30, 2012, 06:37:13 am »

Hello everyone,

Please help me :-)

2.2 what records/docummentation are you responsible for updating?
     how do you maintain confidentially whilst updating records?
  how do you maintain cofidentiality whils sharing information?
 
please help me i dont know how to write in the papers:-(

Thank you so muh for your help.

Lyn x
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maind
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« Reply #1 on: September 30, 2012, 04:10:13 pm »

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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lyn2col
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« Reply #2 on: September 30, 2012, 04:29:34 pm »

HI Maind:-),

Thank you so much for the replied very much apprciated.

3.1 How do you ensure the above are kept up to date, accurate and ligible?

can you explain how do you maintain security of documention?

Please dont understand, other question i answer but this i dont have idea:-(.

Thank you so much for for helping me,
Lyn x
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maind
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« Reply #3 on: October 02, 2012, 04:07:43 pm »

Hi Lyn -

3.1 It is important to ensure records are checked at each shift change to make sure entries have been made which reflect what has occurred during the shift. In addtition, records should be made as things occur and not be all written down at the end - that way, the information will be fresh and accurate. If records are legible they will be easy to follow and more importantly, can support you if you have to go to court about an issue. The person who carried out the care should document it - it is poor practice to ask other staff what a person's pressure sore looked like and then document this if you didn't actually see it for yourself! If there are issues around a staff member's record keeping, these should be flagged up to your manager to take appropriate action because proper are so vital for accurate care - other staff can access them and update themselves if necessary. If you think about a community care organisation, you may not have other staff to hand to ask questions of.

Documentation should be securely locked away with limited access to keys - data stored within such records can allow identity theft if it were to fall into the wrong hands and can also cause a loss of trust if information is lost or inappropriately shared. If information is required by another organisation, it is important to ensure your manager deals with the request - identity of the individual requesting must be established and consent given by the service user or, if they lack capacity, an advocate. Computerised records must be password protected and screens must not face areas where the general public can see what is on the screen. It is also vital to log out if you need to leave your computer for any length of time to prevent abuse of your log-in details to access information inappropriately.
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