what are health records and their function?
how we store patient records.
“Information created, received, and maintained as evidence and as an asset by an organisation or person, in pursuance of legal obligations or in the transaction of business.“
what is the primary function of health records?
to record important clinical information which may need to be assessed by the healthcare professionals involved in care.
to also help improve public health and their services providied by nhs
what are some types of health care records?
- Handwritten notes
- Computerised/electronic notes
- Scanned records
- Laboratory results
- X-ray films and other imaging records
- Photographs
- Videos and audio recordings
- Printouts from monitoring equipment
- consent forms
what are the two most important laws related to record keeping?
- Data Protection Act (2018)
- Human Rights Act (1988)
STATEMENT
CONFIDENTIALITY IS VITAL
- It is a criminal offence to breach the Data Protection Act (2018) and doing so can result in imprisonment.
- The Human Rights Act (1988) also states that everyone has the right to have their private life respected. This includes the right to keep your health records confidential.
- all have the right to request for medial documents
what about keeping and storage of health records?
The legal requirements for the keeping of records are set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014:
In Regulation 17- “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided”
In Regulation 17+ 20- any record, paper or electronic, to be kept securely.
retention of health records
how long can maternity records be kept?
-(including all obstetric and midwifery records, including those of episodes of maternity care that end in stillbirth or where the child later dies)
25 years after the birth of the last child.
retention of health records
how long can children and young people records be kept?
Retain until the patient’s 25th birthday or 26th if young person was 17 at conclusion of treatment, or 8 years after death.
retention of health records
how long can mental health records be kept?
20 years or 8 years after the patient has died
retention of health records
how long can all other hospital records be kept?
- (other than non-specified secondary care records)
8 years after the conclusion of treatment or death.
what is the role of the Caldicott Guardian?
A senior person responsible for protecting the confidentiality of people’s health and care information and making sure it is used properly.
Caldicott Guardians should apply the seven principles wisely, using common sense and an understanding of the law. They should also be compassionate, recognising that their decisions will affect real people—some of whom they may never meet.
what are the 7 Caldicott Principles?
1 - justify the purpose for using confidential information
2 - don’t use personal confidential data unless it is absolutely necessary
3 - use the minimum necessary personal confidential data
4 - access to personal confidential data should be on a strict need-to-know basis
5 - everyone with access to personal confidential data should be a wear of their responsibilities
6 - comply with the law
7 - the duty to share information can be as important as the duty to protect patient confidentiality
STATEMENT
the code 10
10 Keep clear and accurate records relevant to your practice
This applies to the records that are relevant to your scope of practice. It includes but is not limited to patient records.
STATEMENT
the code 10.1
10.1 complete records at the time or as soon as possible after an event, recording if the notes are written sometime after the event
STATEMENT
the code 10.2
10.2 identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need
STATEMENT
the code 10.3
10.3 complete records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements
STATEMENT
the code 10.4
10.4 attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation
STATEMENT
the code 10.6
10.6 collect, treat and store all data and research findings appropriately
STATEMENT
the code 10.5
10.5 take all steps to make sure that records are kept securely
