Handling and recording information

1. Aim
Handling and Recording
Information
Level 2 Core Award

2. Aim
To explore and understand the principles
of good record keeping

3. Learning Outcomes
Delegates will be able to:
Explain the importance of documents
Describe secure record keeping systems
Explain how to maintain good records
Understand the appropriate use of language
Know when and how to share information incl.
Caldicott Guidelines
Explain confidentiality and the Data Protection Act

4. Importance and Types of Documents
All records are important
Needed for consistency of practice
Needed for finding patterns
Needed to inform treatment
Check before you dispose of any records, they may
need to be kept

5. Secure Systems
Secure systems are needed for both
Paper documents
Computer records

6. Maintaining Good Records
Legible
Accurate
Signed, dated and time
No alterations
Chronological
Factual
Not falsified

7. Maintaining Good Records
You are required to demonstrate how you keep
records up to date, complete, accurate and legible

8. Language
“She was going over the top so I burst her bubble by
ignoring her”
“He was going off on one so we told him to pull his neck
in and behave”
“She was having one of her turns so we did what we
always do”
“He was climbing the walls so we thought hey ho here
we go again”

9. Sharing Information
Caldicott Guidelines
You need to be able to justify the purpose for sharing
confidential information
Only use it when absolutely necessary
Use the minimum that is required
Access should be on a strict need-to-know basis
Everyone must understand their responsibilities and
comply with the law

10. Confidentiality
Information should be marked confidential and locked away
Individuals should not be discussed outside of professional
settings and without reason
Information should only be shared where permission has
been given
Remember the Caldicott guidelines

11. Legislation
Data Protection Act 1998
Access to Health Records Act 1990
Health and Social Care Act 2008
Human Rights Act
Care Act 2014

12. CQC
Records about care, treatment and support are clear, factual
and accurate and maintain the dignity and confidentiality of
the people who use services
From Fundamental Care Standards – Care Certificate

13. Support With Handling Information
Manager
Colleagues
Policies and procedures
Training
Information Commissioners Office

14. Dignity in Care
Take a few minutes to reflect upon the way that we
complete records
Has the course encouraged reflection on how good
record keeping contributes to the quality of life?
Are the people we provide services to receiving „best
practice and best service‟?