Describe about the Key issues in keeping accurate confidential patient records (UK Law)?
Key issues in keeping accurate confidential patient records (UK Law)
In current world scenario where there is manipulation and theft of data, information is needed to be kept protected (Ward, 2014). Data gets mishandled when there are a large number of visits of people in one place and healthcare industry is one such place where the population strength is never less (Charlesworth, 2006). Thus here there is a high chance of mishandling of data (Castledine, 2006).
A patient’s information is very vital and sensitive that needs to be protected. Disclosure of which may lead to severe consequences. A patient’s records contain much information like name, age, address, family members, phone numbers, etc. If any other party is trying to harm the patient or patient’s family, he or she may mess with the information. Also it includes the data on medical checkup, the disease the patient is having, operation dates, the operation results, etc. These informations should be kept safely by the medical authorities or the institution so that no destructive doings happen which puts the patient and its family in danger, also putting the reputation status of the medical organization at stake. The patient’s record keeping should be very accurate. It should be exact, simple and should plainly distinguish all details, verdicts, findings and suggestions (Cave, 2009). Sometimes the medical authorities find themselves in quandary where they have to provide information to the people like social workers, insurers, relatives, etc (Dimond, 2004). Sometimes patient’s information is accessed for payment issues, appointments, audit, research, etc. Information Governance in UK has been produced to protect the confidentiality and disclosure of the patients in UK (Selvam, 2015). The law in UK which protects the information about the patients can be jotted down as follows:
- Information of patient should be disclosed with the consent of the patient.
- Identification of people who access information of the patient without any authority.
- Patients ‘should have the right to access their medical records.
- Patients records should also be allowed to created and transmitted by electronic media.
- No data of the patient shall be given for research with the approval of the patient.
- Data from external authority such as x-ray, pathology should be monitored and kept a record.
- Recordings of the patient for their care.
Consent of the patient in UK is very vital as the patient must be the one who will give the permission before they are attended and treated by the medical authorities (Hey, 2009). It should be given to the immediate healthcare authority that will treat that particular patient (Russ, 2010). This is a part of the medical ethics. It can be done in two ways:
- Written: Taking an approval from the patient by signing a contract.
- Verbal: Saying them that they are glad to have an MRI or x-ray.
There are many emergency services in UK which are immediately available for the people with severe injury and illness and those are free service at the moment of care. Emergency cars and ambulances are always available regardless of the status of the patient whether he is a resident of the country or not.
NHS 111, a service that is introduced in England to make it simpler to access the local service of healthcare. It is available all the time, 24 hours and 365 days. People can call for this service whenever there is an emergency situation. It is a service of trained doctors, advisors, nurses who are experienced (Wachter, 2008). They ask questions to interpret the symptoms of the patients and give advice or else assist the patient to the nearby healthcare service (Tortora and Derrickson, 2011).
Castledine, G. (2006). The importance of keeping patient records secure and confidential. Br J Nursing, 15(8), pp.466-466.
Cave, E. (2009). Adolescent Consent and Confi dentiality in the UK. European Journal of Health Law, 16(4), pp.309-331.
Charlesworth, A. (2006). The future of UK data protection regulation. Information Security Technical Report, 11(1), pp.46-54.
Dimond, B. (2004). Healthcare professionals and euthanasia: current law in the UK. Br J Nursing, 13(15), pp.922-924.
Hey, E. (2009). Keeping confidential information confidential. The Lancet, 373(9664), p.630.
Russ, K. (2010). Risk Assessment in the UK Health and Safety System: Theory and Practice. Safety and Health at Work, 1(1), pp.11-18.
Selvam, A. (2015). â€œFirst Aid? Please? First Aid?â€Â. Annals of Emergency Medicine, 65(3), pp.337-338.
Tortora, G. and Derrickson, B. (2011). Principles of anatomy & physiology. Hoboken, N.J.: Wiley.
Wachter, R. (2008). Understanding patient safety. New York: McGraw-Hill Medical.
Ward, L. (2014). Record-keeping and documentation. Nursing Standard, 29(15), pp.61-61.