“Devise a list of guidelines for staff to follow when completing records of clients”
Following the six principles of the Caldicott Report which clarifies the need to protect and respect patients /clients privacy, identity and confidentiality at all times re: their medical history/diagnoses/Care and Treatment.
These are following are guidelines based on the Caldicott Report, that I would recommend for staff to follow when completing clients records.
* “Justify the purpose”: Client’s identifiable information that is used within the organisation should only record what is required, it must be accurate and clearly written, up to date, relevant and regularly reviewed by a senior member of staff.
* “Do not use identifiable information unless it is absolutely necessary”: When recording information write only what is necessary and be aware that the client or advocate can access their records if they wish.
* “Use the minimum necessary re patient’s identifiable information”: Where the use of patient’s identifiable information is considered to be essential, only record relevant information that is required or requested.
* “Access to patient identifiable information should be on a strict need to know basis”: Only relevant staff that need to access clients records should have access to the relevant information they require. Policies and procedures should be in place to protect clients privacy and if this violated action must be taken.
* “Everyone with access to patient identifiable information should be aware of their responsibilities”: Staff must be aware of their responsibility and obligations to respect patient/client’s confidentiality. A confidentiality agreement should be signed by staff. Hard copies of records should be kept in a locked file and key held by the person in charge. Information held on computer
* “Understand and comply with the law”: The organisation has a responsibility for ensuring that they are...