what is a record?
any information about an individual that is being written down or recorded electronically
what is your role in relation to record keeping?
ensuring timely, accurate records for every interaction and how you have provided care for the individual
written records (paper or electronic) must be..?
- accurate
- timely
- detail on care
- factual and recorded according to legislative requirements
- free from abbreviations and jargon
what must you ensure when record keeping?
- competence using all given systems
- confidentiality and data protection
what are audits?
they involve tracking activities and behaviours to see whether they comply with workplace policies and procedures
as audits of records occur, what must you ensure when record keeping?
- handwritten notes are legible and in black ballpoint pen
- data entered accurately when completed electronically
- all entries have a dat, time and signature
what is the purpose of collecting personal information?
- creates a personal patient history
- informs the dignified of a condition or an illness
- identifies treatment received
- identifies follow-on care needs
what is the purpose of storing personal information?
- so it can be shared (as appropriate) with the multidisciplinary team involved in diagnosis, treatment and care
- future use (future treatment or part of research)
- individuals have the right to access their data and records
how is personal information protected?
- data protection regulations (GDPR through Data Protection Act 2018)
- information governance
what is information governance?
a legal framework which establishes that personal info may be shared to others giving direction patient care but protects confidentiality when used for other purposes
why is the patients NAME required when obtaining a client history?
patient identification and their records maintained and tracked
why is the patients DATE OF BIRTH required when obtaining a client history?
- patient identification and their records maintained and tracked
- age affects risk, drug dosage and consent
why is the patients NHS OR HOSPITAL NUMBER required when obtaining a client history?
patient identification and their records maintained and tracked
why is the patients HEALTH STATUS required when obtaining a client history?
may influence care and treatment decisions
why is the patients MEDICATION/ TREATMENT HISTORY required when obtaining a client history?
confirms history of relieving a new or pre-existing condition
why is the patients FAMILY HISTORY required when obtaining a client history?
genetic predisposition to certain conditions or genetically inherited condition
why is the patients SOCIAL HISTORY required when obtaining a client history?
who they live with, their job and lifestyle factors (diet, exercise and substance use)
why is the patients SOCIAL CARE INVOLVEMENT required when obtaining a client history?
whether they’ve received any care from social care agencies
what does PRN stand for?
Pro Re Nata (as required)
what does BP stand for?
blood pressure
what does MAR stand for?
medication administration record
DNR
do not resuscitate
what does MST stand for?
malnutrition screening tool
what does NEWS 2 stand for?
national early warning score (adult physical observation chart used to calculate a score)
