Other professionals and partner organizations that provide information or reports should be advised that the information they provide may well be included in and can access the child`s file. The most important pieces of legislation regarding the recording, storage and disclosure of information are the Data Protection Act (DPA) 2018 and the UK General Data Protection Regulation (UK-GDPR). The legal requirements for record keeping are set out in Regulation 20 of the Health and Social Welfare (Regulated Activities) Act 2008 2010. The first part of the regulation explains why records are required – providers who do not have relevant information endanger the health, well-being and safety of their service users, who will then not benefit from the services provided. The Freedom of Information Act 2000 allows individuals to request certain information held by public authorities, including the government, local authorities, police, hospitals and GP practices. Case registration is a professional tool that proves contact and work with the service user, other colleagues and partner agencies. In addition, phone calls, text messages, letters, emails, meetings and other events related to the case must be recorded. It is expected that the majority of a child`s file will be stored electronically, but it is recognized that some original documents must be kept on paper. This Directive shall apply to paper and electronic records. Practitioners are obliged: the child`s files are an important source of information for them, as well as a tool for planning actions and interventions.
It provides information on the sequence of events that led to a Children`s Services Trust intervention in their lives and explains why important decisions were made in the child`s or family`s life. Case registration is essential to help a child understand themselves and their past, especially if they have not been able to live with their parents or other long-term caregivers. In all cases, parents and holders of parental responsibility should, as far as possible, receive paper copies of documents drawn up about them and their children; For example, assessment documents, assessment plans and child care plans. This is in line with the basic principles of registration, namely that families and children must be able to understand the documents and that they must be accessible to them at all times. After laying down the requirements for the keeping of certain registers, Regulation No 20 addresses the question of how registers are to be kept. The file (paper file and information mosaic) should only be consulted for the following purposes: active case work (including quality assurance) and for research or other departmental reporting purposes (e.g., aggregation for inspections, reports for ministers, etc.). Any user who accesses records for purposes other than those set out above may violate IT security or information assurance policies and may be subject to disciplinary action. Children and their families should be informed of the types of information/data contained in their records. Other laws that have an indirect link to the processing of information include: « Recording good cases is important to demonstrate staff accountability.
It helps focus employee work and supports effective partnerships with service users and caregivers. It shall ensure that it documents how the competent authority has involved individual service users, families and carers and supports continuity when workers are unavailable or change. »; As a caregiver, you have access to the personal data of others, so you need to know the legislation and best practices when it comes to recording, storing, and sharing information. The assessment file contains information explaining how families can access their records and this should be used consistently in the participation of children and families in the exchange of information in the first place. Each child`s file must include details about the child`s full name, date of birth, ethnic origin, any disability and identification number. Care must be taken to ensure that the spelling of names is correct and, if possible, proven, for example a birth certificate. In some cases, key information may change, and it is important that the file identifies the current situation of the child or family. In such circumstances, ensure that the information shared is necessary for the purposes for which it is shared and is only shared with those who need it. The data protection authority shall strike a balance between an individual`s right to privacy and an organisation`s right to store their data by ensuring that personal data is secure, can only be used for what was originally intended at the time of collection, is accurate and up-to-date, and should be deleted when they are no longer needed. In situations where workers deem it necessary to keep case information away from their secure base, all necessary measures must be taken to ensure their safety. Paper files can only be removed from their official location if the team leader has given explicit permission.
The Data Protection Act 2018 contains 8 main principles that directly concern the registration of the case and the information stored in the file. These can be summarized as follows: Record keeping is an important, albeit time-consuming and often boring activity for nursing service providers and their staff. You need to keep many types of records, all of which contribute in one way or another, but not always obvious, to the well-being of users of the service. As it cannot be avoided, it is worth having an effective system that meets all legal requirements. This means that the record is treated as a complete system that is planned, managed, reviewed and improved as a whole. If this is not possible and the records are completed or updated by others, the registry indicates who provided the information collected. Preferably, the creator should read and complete the recording on Mosaic to ensure its accuracy. In some areas, there are special confidentiality requirements, such as adoption records. Policies and procedures in these areas should be followed and expert advice sought.
Children and their families must be regularly involved in the process of collecting and recording information about them. You should feel like you are part of the registration process. Records confidentially link information about the person relating to his or her past or to his or her care and treatment by other professionals and bodies Children and their parents must be asked to give their consent to the disclosure of information about themselves with other Persons Information must be shared, where appropriate, with the consent of the child and family and, if possible, with the wishes of those who: those who do not want confidential information to be disclosed should be respected. Information may continue to be shared without consent if it is in the public interest. Decisions regarding the sharing of information should be based on the consideration or safety and well-being of the person and others who may be affected by the disclosure. Where paper records are also retained, the information stored in electronic records accurately reflects the relevant information recorded in paper records. In February 2021, a link to the Children`s Services Trust`s new guidelines on case summaries was added. The guidelines explain the purpose of case summaries and explain what should be included in a summary and how often they should be prepared. Doncaster Children`s Services Trust expects a high level of record keeping to be maintained at all times.
The purpose of this policy is to define record retention requirements for all employees involved in creating, maintaining, monitoring or participating in social care records. Each child must have their own electronic file from the time of referral until the case is closed. Audio, video and digital recordings may also be retained. Lawyers working for service users sometimes request access to a file that can be used in criminal or civil proceedings. If such a request is received, the matter must be immediately referred back to the Legal Service for consideration. The record takes into account the individual`s needs for dignity and confidentiality, which means it should never be abusive, critical or defamatory The Caldicott Principles are seven basic principles for protecting the personal information of nhS patients. This is the data protection legislation that imposes the same strict requirements on the Trust with regard to access and storage of personal data, whether stored on paper or in electronic form. Paragraph 1(b) of Regulation 20 requires care providers to maintain appropriate records of the persons employed to provide the service (i.e., personnel records) and the administration of the service.