UNIT 4222-307 Promote good practice in handling information in health and

social care settings

1. Understand requirements for handling information in health and social care

settings
1.1 Identify legislation and codes of practice that relate to handling information in health
and social care
There are many pieces of legislation related to handling information, and they cover all
aspects from general to the most specific. First of all coming in my mind is Human Rights
Act 1998 which mentions the right of privacy retained by the service users even if they are
no longer able to give a valid consent about it. Another two documents, Data Protection Act
1998 and Freedom of Information Act 2000 give us details about processing information,
whether it is about written or electronic systems, and also about recording, storing and
sharing it. And about codes of practice, The Caldicott Principles and The Code of Conduct
for Healthcare Support Workers and Adult Social Care Workers in England are the most
relevant, providing examples of good practice based on common sense and at the same time
covered by law.
1.2 Summarise the main points of legal requirements and codes of practice for handling
information in health and social care
- Justify the purpose(s): explain clearly WHY it is necessary to pass this information (the
causes and the effects of this action), and state it in writing for further references
- Don't use service user identifiable information unless it is necessary: patient identifiable
information are name, address, telephone number, email address, next of kin, ID and other
documents and they have to be used only in extreme need
- Use the minimum necessary service user identifiable information: be careful to the steps
taken to achieve the purpose and insert these information only at a high level requirement
- Access to service user identifiable information should be on a strict need-to-know basis:
only the ones who must know and only the ones who have the right to know are entitled to
access these information
- Everyone with access to service user identifiable information should be aware of their
responsibilities: people handling service user identifiable information - both clinical and non-
clinical staff – have to be aware of their responsibilities and obligations to respect service
user confidentiality.
- Understand and comply with the law: every use of patient identifiable information must
be lawful. Someone in each organization handling service user information should be
responsible for ensuring that the organization complies with legal requirements.
- The duty to share information can be as important as the duty to protect service user
confidentiality: any information handling and sharing action should be taken in the service
user’s best interest.
2. Be able to implement good practice in handling information
2.1. Describe features of manual and electronic information storage systems that help ensure
security
- Keep the paper-based files and folders tidy and safe, even locked in a secure place (e.g.
drawers, cupboards)
- Electronic recording systems must be kept safe and protected by strong firewalls and
frequently changing passwords, and also limitate the number of people who have access to
this system
- Do not keep information longer than necessary, this helps saving space and also keeps the
electronic system secure and away from errors by avoiding over-uploading information
2.2 Demonstrate practices that ensure security when storing and accessing information
For example, I am registered with an agency that provides HCAs for the social care settings
that need extra staff in certain days, and I am currently working as 1:1 care assistant for a
resident in a nursing home, and I only do day shifts. When I started, I completed the
induction with the nurse in charge, and among other details she gave me the resident’s care
plan to make myself familiar to him. This folder was kept in a special rail in their office. The
access to the office is provided by an electronic code typed on a keyboard which
automatically releases the door and of course I have no access there. After I read all the
information I needed to make a good start, I handed back the folder to the nurse who
carefully put it back and locked the office. As my patient is a new resident admitted in the
home, I have to observe and fill in certain forms during the day, such as food/fluid charts and
daily records. These forms are available in a plastic folder in his room on the bedside cabinet,
and after filling them in I have to file them in chronological order, and after a full month I
have to hand them to the nurse in charge, and she will follow their local organizational
procedure concerning storage.
2.3 Maintain records that are up to date, complete, accurate and legible
As I mentioned above, I have to fill in some forms, and some of them require at least one
entry per hour. I always make sure I use black ink and make my handwriting legible for easy
photocopying if necessary. When I start the day, I put down the date in DD/MM/YYYY
format and time in 24-hour format. I put down the time at every entry. After I finish every
entry I cross the row with a line up to the end, I sign and put my initials. Sometimes during
an entry I have to rephrase as my English is limited when it comes for specific terms, and
then I cross the wrong word/phrase with a line to keep it visible though, and I continue after.
If I have to correct a previous mistake (mine or not), I cross the word/phrase, write above or
on a side, date, time and sign for further references. When filling in information I avoid
giving personal opinions, I give facts, statements and quotes. I also avoid abbreviations,
except from the agreed ones (provided in the printed forms).
3. Be able to support others to handle information
3.1 Support others to understand the need for secure handling of information
There are some aspects that I find important concerning handling information:
- Keep confidentiality (only the ones who have the right to know and only the ones who
must know)
- Respect the local/organizational policies for recording, storing and sharing information
- The senior colleagues, supervisors and managers are always ready and available if
needed, especially if we are worried about the security of the systems we use
- Process the information fairly and lawfully, for limited purposes and in accordance with
the individual’s rights
- Do not transfer to countries outside European Economic area unless country has adequate
protection for the individual
3.2 Support others to understand and contribute to records
Being a day-time 1:1 care assistant means that I have to hand over the shift to the night care
worker who takes the charge. It happens very often that new colleagues come in and I have to
show them the forms they have to fill in, how to file them, where they find the blank forms
when they need them, and also tell them who is the nurse in charge and where the office is.
Sometimes the home operates some changes and the nurse or senior staff hand them to me,
so I have the duty to inform the night worker who takes over about the changes.