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Mind Your P’s and Q’s
Take care that care records are fully confidential; you may not be the only one to have access to them.
A cursory read over of a care plan this week left me concerned enough to issue this timely reminder to all of those who are responsible for records. Here’s an excerpt:
“Please can you all make sure that Charlie does not get into Archie’s cupboard because today I found he had eaten some of the gluten free biscuits that Mrs Brown left for Christmas? Archie was really angry and scratched Charlie’s hands trying to get the biscuits off him. We have to make sure that Charlie has the scratches looked at because of Archie’s MRSA.”
So we know that Charlie is light fingered where biscuits are concerned. We know that there was an altercation and he was scratched. We know that we have to review the wounds and check them for infection.
However, we also know that Archie has gluten free biscuits, that he has a relative or friend called Mrs Brown, and that he has MRSA. And all from Charlie’s care note.
Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 requires us to keep and manage records in the best interest of the service user and in line with legislation on data protection. The registered person must ensure that service users are protected, by means of the maintenance of an accurate record in respect of each service user, which shall include appropriate information and documents in relation to the care and treatment provided to each service user.
It doesn’t specifically state that one service user’s record should not refer to, identify or disclose information about another. However, in the event that access to the record was requested by a relative or person acting on behalf of the service user, how could we make sure we were maintaining confidentiality?
Tippex is a wonderful thing; I have seen colleagues hard at it with the white stuff and photocopied records in order to undo the breaches of confidentiality that regularly happen when records are made of day to day group living. But why take the risk? Make sure your staff understand the basic rule; one care plan for one person, no identifying details of anyone else should be added to notes. Refer to staff if necessary for the purpose of governance; for example:
“Charlie was supported by Jane Clarke today at the surgery and Dr March dressed his scratches.”
But keep Archie out of it!
You can get information about confidentiality and record keeping in the policies stored under QCS Care Management
Ginny Tyler – QCS
" href="http://www.ukqcs.co.uk/cqc/learning-disability/" target="_new" data-tooltip="Learning disabilities have an impact on a service user’s everyday life, which in turns places specific demands on providers of care who specialise in services that offer support to those with learning disabilities. Everything from arranging a visit to a shop, to going on a bus, to meeting someone new, can for some be a profoundly difficult undertaking, so appropriately qualified care providers are on hand to offer their expertise and guidance to make the lives of their service users that much more simpler and enjoyable.<br /><br />Learning disabilities are a broad spectrum and include Down’s Syndrome, Autism, Aspergers Syndrome, Fragile X Syndrome and many more. It is distinct from learning difficulties, such as dyslexia, which do not impact upon intellect. With the right care and management people with learning disabilities can still lead normal lives. Profound and Multiple Learning Disabilities (PMLD) present even greater challenges to the care service, but there are many services throughout the UK equipped to deal with even the most significant of learning disabilities.">Learning Disability Expert Contributor