Record Keeping Clinical levels 1,2, & above

Record KeepingClinical levels 1,2, & above Facilitated learning workshop

Fire exits Toilets Tea coffee Breaks/lunch Mobile phones Smoking policy House keeping

Introduction

Aim: To provide an opportunity to review, reflect and consider the quality of records kept within our area of work. Record Keeping facilitated learning

Roles & function • Facilitators • Assessors

Programme

Consistent with DCHS policies & tools • Clinical Record Keeping Policy • Clinical Record Keeping Standards • Accepted abbreviations • Record Keeping audit tools

REFLECTING PROFESSIONAL STANDARDS

Learning Outcomes • The factors that support good record keeping • The importance and benefits of good record keeping • Principles of good record keeping and how to apply them • Responsibilities associated with handling confidential and sensitive information • Methods for audit and continuous improvement

Objectives learners will be able to: • State the governance framework in place for records and records management • Exercise safe practice in information security • Explain the consequences of poor quality record keeping exposed by contemporary investigations • Demonstrate evidence in meeting the Derbyshire Record Keeping Standards • Evidence the principles in record keeping • Audit and take action to improve their own record keeping practice and that of their peers

Evidence of having achieved the learning Outcomes & Objectives Proof of learning activities for appraisal, professional CPD portfolio (workbook/activity sheets) Personal development and career progression-KSF Record Keeping Skills Passport (Assessment tool) Better records and hence improved reports and statements Reflected in Clinical Records audit Improved quality in care!

Link to the DCHS Intranet

Exercise 1

Main legislation • Data Protection Act (1998) • Computer Misuse Act (1990) • Human Rights Act (1998) • Freedom of information Act 2000 • NHS Constitution 2009

Data Protection Act 1998 http://www.dh.gov.uk/en/Managingyourorganisation/Informationpolicy/Recordsmanagement/DH_4000489 Records Management: NHS Code of Practice 2006 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4131747 Freedom of information Act 2000 http://www.opsi.gov.uk/Acts/acts2000/ukpga_20000036_en_1 NHS Constitution http://www.dh.gov.uk/en/Healthcare/NHSConstitution/index.htm

Patient records serve two purposes: • To support direct patient care, acting as an aide memoire for clinicians and aiding clinical decision making • To provide a legal record of care to support clinical audit, research, resource allocation and performance planning

What constitutes a patient/ clinical record ? Derbyshire Community Health Services Clinical Record Keeping Policy (on the intranet) breaks the definition down into “Clinical” & “Record”. • Clinical: Relating to observation and the treatment of patients • Record: Register set down for remembrance or reference, which is in permanent form, and provides evidence of information. Clinical records may also be defined as those records maintained by registered health and allied health professionals in accordance with their professional registration standards

The principles of good record keeping apply to all types of records including: • handwritten clinical notes • emails • letters to and from other health professionals • laboratory reports • x-rays • printouts from monitoring equipment • incident reports and statements • photographs • videos • tape-recordings of telephone conversations • text messages & facsimile messages

'if it is not recorded, it has not been done'Courts of law tend to adopt this approach based on the assumption that: • on any given day a nurse or midwife may provide advice or treatment to a large number of people in their care. In contrast: • the person in their care will not receive advice very often.

Why do we keep records?

Reasons include: To provide an accurate account of assessment, treatment, planning, evaluation and delivery A documentary record of part of the history of that patients’ healthcare. As a record of the care provided /service providers involvement • As a legal requirement and stand up to legal scrutiny. • Demonstrates patients capacity to consent and agree to treatment given • Demonstrates patient involvement in decisions about their care • Professional accountability

To provide an audit trail, a documented record of accountability • To promote high standards of care and confidentiality • To help to illustrate any patterns of behaviour • As a statement of the purpose of the work, to show care is planned and not a haphazard series of events • To avoid duplication • To ensure continuity • To help form professional judgements • To provide information for referral • To promote continuity of care

To help form professional judgements about care or treatment promoting the ability to identify risks, and detect problems • To provide information for a referral to another agency • To promote continuity of care given and communication between different practitioners or the multi-professional team involved in the provision of care

What does the legislation say about how organisations must communicate its Protection Policies to the public (including patients and service users)?

There is a legal duty to communicate in ways which recognise diverse cultures and methods of communication (i.e. translation of documents must be available as well as different media to cover different sensory conditions)

Which agencies and organisations are covered by the legislation? • What is the legal term for the ‘person you keep the record about’? • Can you alter a record, once you have written it? • What does the legislation say about the use of jargon, coded language or personal judgement?

The NHS Constitution

Exercise 2

From your experience and observations, what do you think are the most common errors in record keeping?

Commonly reported errors • Dates and times omitted • Illegible handwriting • Lack of entry in the record when an abortive call/visit has been made • Abbreviations were ambiguous • Record of phone call (e.g. to social services) that omitted the name and designation of the recipient (e.g. social workers). • Use of correction fluid and covering up errors • No signature • Absence of relevant information • Inaccuracies, especially of date • Delay in completing the record, sometimes more than 24hours elapsed before the records were completed. • Record completed by someone who did not deliver the care • Inaccuracies of NHS number, name, date of birth and address • Unprofessional terminology, e.g. ’dull as a doorstep’ • Meaningless phrases , e.g. ‘lovely child’ ‘appears’ ‘Slept well’ ‘Encouraged’ • Opinion mixed with facts. • Reliance on information from others without identifying the source. • Subjective not objective comments, e.g. ’normal development’ Adapted from Dimond.B. (2005) Legal Aspects of Nursing

NMC professional adviser Martine Tune ‘it’s about a change in thinking – records are as important as the care we’re providing to the person. We also see record keeping consistently in the top three reasons why people appear before Fitness to Practise panels…’ NMC 2009 Fitness to Practice hearings

Review a set of notes relevant to your area of work, see where the following should be recorded: Three patient identifiers: the patient’s name, NHS number and date of birth.

NMC professional adviser Martine Tune ‘it’s about a change in thinking – records are as important as the care we’re providing to the person. We also see record keeping consistently in the top three reasons why people appear before Fitness to Practise panels…’ NMC 2009 Fitness to Practice hearings

Exercise 3 National and local policy framework

Safe Haven • Passwords • Electronic equipment • Email • Text • Facsimile • Electronic records

Data Protection Principles: • Information to be obtained and processed fairly and lawfully • Personal data shall be obtained only for one or more specified and lawful purposes • Personal data shall be adequate, relevant and not excessive in relation to the purpose(s) for which they are processed • Personal data shall be accurate, and where necessary, up to date • Personal data shall not be kept for longer than necessary

Data Protection Principles: • Personal data shall be processed in accordance with the rights of the data subjects • Data must be kept secure • Personal data should not be transferred to a country or territory outside the economic area without adequate protection

Caldicott principles 1.Justify the purpose(s) for using patient data 2. Don't use patient-identifiable information unless it is absolutely necessary 3. Use the minimum necessary patient-identifiable information 4. Access to patient-identifiable information should be on a strict need to know basis 5. Everyone should be aware of their responsibilities to maintain confidentiality 6. Understand and comply with the law, in particular the Data Protection Act As an employee of an NHS Trust you are required to follow the Caldicott principles

TheInformation Governance Code Think- when using personal information Handle-information securely and sensitively Encrypt-all laptops, and memory sticks Information-if it’s personal, it’s private Governance- you are accountable for personal information and to deliver good clinical care Confidential-prevent unauthorised disclosure/sharing Overheard-remember, sound travels! Do not- share passwords or smartcard PIN numbers-ever! Everyone-we all have a legal duty to keep personal information safe and secure

Exercise 4 What we write and how

Fact & Opinion • The term fact can refer to, depending on context, a detail concerning circumstances past or present, a claim corresponding to objective reality, or a provably true concept. • An opinion is a belief that cannot be proved with evidence. It is a subjective feeling and may be the result of an emotion or an interpretation of facts; people may draw opposing opinions from the same facts

Exercise 5 Quality in Recording

Mental Capacity The Mental Capacity Act 2005 provides a framework to empower and protect people who may lack capacity to make some decisions for themselves

Mental Capacity Act 2005principles • Every adult has the right to make his or her own decisions and must be assumed to have capacity to make them unless it is proved otherwise. • A person must be given all practicable help before anyone treats them as not being able to make their own decisions. • Just because an individual makes what might be seen as an unwise decision, they should not be treated as lacking capacity to make that decision.

Mental Capacity Act Principles contd. • Anything done or any decision made on behalf of a person who lacks capacity must be done in their best interests. • Anything done for or on behalf of a person who lacks capacity should be the least restrictive of their basic rights and freedoms.

Mental Capacity Act and DOLSweblinks http://www.opsi.gov.uk/acts/acts2005/ukpga_20050009_en_1 http://www.publicguardian.gov.uk/mca/mca.htm http://www.publicguardian.gov.uk/about/dols-code-laid.htm http://www.publicguardian.gov.uk/docs/draft-dols-code.pdf

Guidelines • Hand written records must be written legibly • Stick to the facts • Avoid labelling and eliminate bias • Be specific • Use neutral language • Keep the record intact • Use verbs to denote an action (e.g. Mrs Bloggs read the paper today) or an occurrence (there is suppuration at the injection site), or a state of being (Mrs Bloggs stood without assistance).

Use adjectives to give more information about the noun (e.g. Mrs Bloggs sputum is clear/green) • Where possible provide a measure/quantify, or period of time • Substantiate your record with example (s) in support of your judgement Use your senses to record what you did, such as ‘I heard’, ‘felt’, ‘saw’. Use quotation marks where necessary, such as when recording what was said to you. • Use only accepted abbreviations

Clinical Coding Where the following wording is used in records, it is not possible to attribute a code: • Differential Diagnosis ( ∆∆ ) • Possible • Likely • Maybe • Suspected • ? • Impression

Record Keeping Clinical levels 1,2, & above