3 Handling information

Within your healthcare assistant role, you will be asked to handle various pieces of information given to you regarding patients and their needs; including confidential information about individuals and possibly their families or carers. The Data Protection Act (1984) first introduced rules on how to store information and who will be given permission to access such data, which are still in force today (subject to the Data Protection Act, 1998).

If you work for a public authority such as in hospitals or doctors’ surgeries you should be aware that patients have a right to view anything written about them. They can make a formal request for this through the Freedom of Information Act (2000). This may include documents, reports and even emails between healthcare workers. Patient care plans can become legal documents of evidence if at any point there is cause for legal action, so if you add to any of these records you need to remember that what you write must be accurate and suitable to be viewed by those it concerns.

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Figure 4 You might be asked to handle or contribute to hard data within a paper filing system

Problems would be likely to arise if no records are kept. For example, a patient who is allergic to penicillin could be given inappropriate care and prescribed penicillin as it wouldn’t be shown on her medical history.

Another example of why keeping records is important would be to help care workers remember past actions and future plans, otherwise details and even major issues might be forgotten, time would be wasted finding out the same information again, and repeating some forms of care, such as medical treatments, could be harmful.

In Activity 8, look at the examples and think of a problem that might arise if records are not kept. Try to write an example from your own experiences of healthcare services, click to save it and then click to reveal the comment.

Activity 8

Timing: Allow about 25 minutes
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(Activity adapted from K101 Learning Guide 14, Open University 2015a)

2.1 Barriers to good communication

3.1 Medical records