Develop, maintain and use records and reports
1. Understand the legal and organisational requirements for recording information and providing reports.
1.1 Specify own responsibilities and those of others when recording information and producing reports.
To ensure the necessary safeguards and appropriate uses of personal information are in place. For example, any issues relating to human rights, the duty of confidentiality as part of duty of care, accuracy. The information is permanent once it has been written down. The information is very personal for example, bank details, medical history and family background. This needs to be kept as confidential as possible by the manager or care workers that are recording and producing reports.
1.2. Explain the legal requirements and agreed ways of working for the security and confidentiality of information. The main piece of legislation is the Data Protection Act 1998. This covers the medical, social, credit information and the local authority. There are eight principles. The data must be:
Fairly and lawfully processed
Processed for intended purposes
Adequate, relevant and not excessive
Not kept for longer than necessary
Processed in accordance with the data subject rights
Not transferred without adequate protection
2. Be able to prepare professional records and reports that meet legal requirements, and agreed ways of working.
2.5 Explain how to balance the tension between confidentiality and openness in records and reports.
It is important to share information appropriately about the service-users for their health care and to get the best help available to them while remaining consistent with privacy legislation and professional guidelines about confidentiality.
So basically if you record and report within the laws of privacy legislation but within those laws you can be open enough to get the best health care service for the individual.