Promote Good Practice in Handling Information in Health and Social Care Settings

This check was put in place to safeguard people who are vulnerable such as children and persons with a disability.

The information is stored in locked filing cabinets as the information can hold company details and account numbers this is only accessible by the Administration staff and each file is signed out on a register.

Filing systems are used to easily identify where documents and certain pieces of information have been stored, this makes it easier to retrieve for future use as it will limit the amount of time spent retrieving this information.

Some of the benefits of electronically storing are that you can store vast amounts of information in a very small space, you can reproduce and disseminate this information at great speed, documents are easy to modify. Documents can also be searched for easily, and it is hard for the documents to go missing.

Accurate nursing documentation is paramount to increased level of care for a patients that are admitted into hospitals, referred to other providers or discharged from care. An accurate medical record is by far the most reliable source of information on the care of a patient. The proper documentation by nurses prevents errors and facilitates continuity of care.

1. Identify legislation and codes of practice that relate to handling information in health and social care.

As a carer or healthcare provider, some of our obligations are to make sure that information is: utilized reasonably and legally, utilized for restricted, particularly expressed purposes, utilized as a part of a way that is sufficient, applicable and not unnecessary, accurate, kept for no more than is totally fundamental, handled by information insurance rights, kept protected and secure and not exchanged outside the UK without sufficient insurance (Walsh, 2011, p.88).

The Data Protection Act (1998) requires that personal details and information must be kept secure and confidential. Confidentiality is necessary in any Health and Care Social setting because it maintains between the individuals and the organisation. An environment of trust encourages people to be open and honest with those who care for them. They provide all the details necessary so that they receive the best care possible. The employers are accountable to the regulators for protecting confidentiality .Preserving privacy and confidentiality is essential so that they do not risk the discipline of being struck off a professional register. Each member of the staff has a responsibility to ensure that the care record are accurate recorded. A clear information will aid patients to participate fully in decision making about their

1.1 Identify legislation and codes of practice that relate to handling information in health and socail care

The Data Protection Act states that you must only collect information that you need for a specific purpose and keep it secure, ensure that it is relevant and up to date to guarantee that no changes in medication or health status goes unnoticed or unaccounted

Other patient information you may find is documentation for any allergies the patient may have. Insurance information will be noted if the patient is covered were you will find the provider, the billing address, and the patient’s policy number. There will be many different forms in this system that are used to document things such as the patient’s family history, diagnostic results, immunization records, past and present medications taken and the effectiveness of them, and of course there will be doctors notes for any office visits and hospitalizations. In the doctors notes and hospitalization notes you will find documentation for medical conditions or diseases the patient may have had in the past or has presently. Last but certainly not least there will be the common release and authorization forms, there may be advanced directives or living wills on file if the patient has completed them and other relevant information that staff and medical facilities may need to provide quality care for the patient. (Whatis.com, 2008).

Record keeping provides evidence of any interaction or intervention involving a patient. It needs to be comprehensive enough to determine that the nurse has fulfilled his/her legal and professional duty of care (Griffith 2007).

At a practice level, the importance and guidance of the Code of Conduct, Code of Ethics and NPA are demonstrated on a daily basis with regard to the issues of documentation, informed consent and open disclosure, and confidentiality. With respect to documentation, nurses must be able to document patient assessments and responses in an accurate, comprehensive and confidential manner and record all observations objectively. Informed consent and open disclosure are also major legal issues nurses face daily. It refers to the communication between the patient and health professional that results in the patient's agreement to undergo a specific procedure and requires that the patient has thoroughly understood the procedure, implications and risks prior to giving written consent.

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The elements of the principles of confidentiality can be broken down into four separate categories: (1) Information provided by the patient is kept confidential unless consent from the patient has otherwise been given—unless it has direct legal implications or endangers the general public. (2) Informed Consent: is given freely, because the correct information has been supplied and the patient has sufficient information on the impacts involved. Information is otherwise given out on a need to know basis. (3) Duty of Care: Information is given out in order to protect the safety and health of others and the patient. Legal and general public health fall under this category. (4) Documenting Decisions: Consultations and actions that lead to