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Jane Beach and Jennifer Oates explore the issues and importance of information governance and record keeping in the wake of the Heath and Social Care Act 2012
Abstract
The quality of health record keeping and documentation has been a cause for concern in recent serious case reviews and inquiries. It is also a source of health professional referral to fitness to practice panels. Mental health nurses' record keeping is governed by national legislation as well as local policy. Recent developments in record keeping practice, not least the progressive move to electronic records, mean that legislation and policy must be reinterpreted to take account of new challenges and dilemmas.
Key words
Record keeping, information governance, regulation, confidentiality, standards
Introduction
This article provides an update on:
* Recent concerns raised about the quality of record keeping in healthcare settings.
* The policy and practice of information governance.
* The role of the Caldicott Guardian and the revised Caldicott principles.
* Good practice when sharing a client's personal identifiable information with colleagues.
Healthcare workers are increasingly reporting difficulties related to record keeping, for example, because of duplication in paper and electronic recording and documentation systems, together with the amount of time it takes to complete care records, ethical and practical challenges in safe access to records and the impact on their practice of developments in social media.
The national serious case reviews published in 2013 identified, among other issues, concerns about healthcare workers' record keeping. These included inaccurate recording of information and a reluctance to share information between agencies.
Similar themes were also identified by the inquiries into care failings at the Mid Staffordshire NHS Foundation Trust (The Mid Staffordshire NHS Foundation Trust Public Inquiry, 2010; 2013), Morecambe Bay (Care Quality Commission, 2012), the National Patient Safety Advisory Group (20131 and Clywd and Hart i2013),
Alongside concerns raised at system and organisational level, poor record keeping is a common factor in health professional fitness to practise cases. A total of 0.6% of nurses and midwives are referred to the NMC in any one year due to concerns about aspects of their practice or behaviour (Nursing and Midwifery Council. 2011).
A review by Unite uf members' fitness to practise retenais in October 2013 found that 25%...