Record Keeping Levels 1 & 2 Non clinical

1. Record KeepingLevels 1 & 2 Non clinical Facilitated learning workshop

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

3. Introduction

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

5. Roles & function • Facilitators • Assessors

6. Programme

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

8. REFLECTING PROFESSIONAL STANDARDS

9. 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

10. 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

11. 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!

12. 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!

13. Link to the DCHS Intranet

14. Resource components • Introduction- Sets the scene and the aim • Exercise 1- Records, main legislation & principles • Exercise 2- Record keeping practice and pitfalls • Exercise 3- National and local policy frameworks • Exercise 4- What we write and how • Exercise 5- Quality in recording • Exercise 6- Audit • Summary

15. Resource material • Exercises with a selection of activities to meet the learning outcomes e.g. Free text, MCQ, Examples of records, recording activities • Video • Sign posting to additional learning material e.g. ICO DVD ‘The lights are on…’ & Connecting for health DVD • Intranet links, website links • Optional reading e.g. Fitness to practice panel reports, Aldermaston ‘body parts’ confidentiality debate

16. Exercise 1

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

18. 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

19. 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

20. 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

21. 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

22. '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.

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

24. Exercise 2

25. 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

26. 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.

27. 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

28. Exercise 3

29. 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

30. 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

31. 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

32. 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

33. Exercise 4

34. 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

35. Exercise 5

36. 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

37. 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.

38. 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.

39. 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

40. 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).

41. 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

42. 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

43. What can be coded: • Definite Diagnosis ( ∆ ) • Treat as • Probably • Presumed • Symptoms where no definite Diagnosis is made

44. Regular summarising the contents of the file may have the following advantages • Enables practitioners to find relevant information quickly without having to hunt through the record for it. • Helps the process of reviewing the case • Helps clarify the aim of the care plan • Provides summaries for longer reports, multi-disciplinary case reviews and court reports • Helps new practitioners familiarise themselves with patients/clients quickly • Enables clinical supervision to be more helpful to the practitioner

45. Plans and objectives should be SMART • Specific and clear • Measurable (or verifiable) • Achievable and realistic • Related to the assessment of need and the overall concerns • Time-related (i.e. within what timescale)

46. SOAPIE or SOAPIER • Subjective – History • Objective –Examination & Investigations • Assessment – Diagnosis/Impression • Plan • Implementation – Treatment and Advice • Evaluation – Review

47. Abbreviations quiz • PID • Pt • CP • MS • NFR • NAD • PCXR

48. PID: pelvic inflammatory disease or prolapsed intervertebral disc? • Pt: patient, physiotherapist or part time? • CP: cerebral palsy or chartered physiotherapist? • MS: multiple sclerosis or mitral stenosis? • NFR: not for resuscitation or neurophysiological facilitation of respiration? • NAD: nothing abnormal detected or not adrop? • PCXR: primary chest X-Ray or portable chest X-ray? Use only the abbreviations or acronyms approved by DCHS

49. Children’s PHR- Red Book

50. Principles to be followed in preparing a statement Always refer to the Directorate Manager and the Legal Services Manager in the first instance for further guidance • Accuracy • Factual • Avoid hearsay • Conciseness • Relevance • Clarity • Legibility • Overall impact • Keep a copy