Case Recording Practice Adults Services

Transcription

1 Case Recording Practice Adults Services Guidance on case recording practice and on document management Version: 3.3 Effective from: 1 st October 2014 Next review date: 1 st Nov 2015 Signed off by: Jenny Daniels Title: Head of Health and Social Care Practice Date: 6 th July 2012

2 Case recording and document management: guidance 2 Current issue: Status Amended existing policy Version number 3.3 Issue date 1 st October 2014 Owner Sharon Gogan, Head of Adult Social Care (from September 2013) Author Greg Slay Signed off by Jenny Daniels, Head of Health and Social Care Practice Date 6 th July 2012 Changes history: Issue Date Author Principal Changes number 3 July 2012 J Bickers, Greg Slay 3.1 January April October 2014 Greg Slay Greg Slay Greg Slay Addition of guidance relating to information security and the confidentiality of paper records used in the course of practice away from the office environment Addition of information relating to the management of documents with wet signatures Information added about West Sussex Connect to Support website Feedback: Our customers expect first class service and we aim to provide it. We therefore welcome feedback about our policies and procedures. If you have any comments about this document please socialcare@westsussex.gov.uk Copyright 2014 West Sussex County Council / Version 3.3 / October 2014 Page 2

3 Case recording and document management: guidance 3 Equality and diversity As part of our commitment to equality and diversity, and in line with the requirements of the Equality Act 2010, the county council will ensure that all customers of our services are treated with fairness, dignity and respect irrespective of any of the following protected characteristics: age, race, gender, disability, sexual orientation, gender reassignment, marriage or civil partnership status, pregnancy/maternity status or religion and belief. Contents 1. Introduction 4 Principles for document management 4 2. Confidentiality of records 5 3. Recording practice paper records 5 Security and confidentiality of paper records 6 Lost or mislaid handwritten case records 7 4. Recording practice electronic records 7 Computer security and confidentiality 7 5. Recording warnings on customer records 8 6. Storage of different types of records 9 Wet signature documents 9 7. Information-sharing principles Managers what you need to do 11 Lost or missing paper case files 12 Copyright 2014 West Sussex County Council / Version 3.3 / October 2014 Page 3

4 Case recording and document management: guidance 4 1. Introduction 1.1 The social care record brings together in one place all the relevant information about social care discussed with, and/or arranged by, Adults Services with customers and carers. 1.2 Staff are responsible for good quality recording and practice that is in line with the county council s various policies and protocols. Consequently this guidance must be shared and explained to all new staff, temporary staff, and students when they first commence working for, or on behalf of, Adults Services. 1.3 New approaches to the appropriateness and safety of sensitive records have been necessitated by the rapid development of electronic communication, mobile working, hot-desking, the widespread availability of memory sticks (encrypted and non-encrypted) and the security requirements and expectations of Government departments and of the Information Commissioner. Locally we have both corporate and directorate-specific approaches in the county council with regard to information security and management and these arrangements are frequently tested for effectiveness. Principles for document management Case records, whether electronic or paper format, are based on business requirements and: use the most efficient approach by minimising duplication of effort wherever possible; create a single view of the customer or carer; enable decision-making based on full current case information; rationalise processes that hitherto often been time-consuming and duplicated; maximise the opportunities to use technology - such as secure to best advantage. The expectation of the Adults Services Quality Assurance Management Board is that our approach to case records is consistently applied across all areas of the business, is in line with the latest data security guidance, and is underpinned and supported by training, policy and guidance. 1.4 This guidance forms part of a suite of documents for Adults Services relating to document management, information security and boundaries for care practice (visit: westsussexconnecttosupport/professionalzone). Copyright 2014 West Sussex County Council / Version 3.3 / October 2014 Page 4

5 Case recording and document management: guidance 5 2. Confidentiality of records 2.1 Any records containing personal data and sensitive information are strictly confidential. This means that paper files must be kept in a locked filing cabinet when in use - or transferred to the corporate File Store if not in use whilst electronic records must be password-protected (hence the security login process for access to Frameworki). 2.2 The contents of social care records relating to customers must not be available or disclosed to anyone without the consent of the person who is the subject of the case record other than to: the individual to whom the record relates (as appropriate); employees and partner professionals with appropriate permissions to access the record solely in order to provide a service, employees and partner professionals with appropriate permissions to access the record in order to facilitate the investigation of a potential or actual crime; managers who are undertaking a quality assurance exercise; HM Courts and Tribunals Service if directed to do so. 3. Recording practice paper records 3.1 Before making any record in long-hand, whether as rough notes of a meeting with a customer or in completing a template form downloaded from Frameworki, social care staff should always think about the purpose and content of the record and who may be interested in having access to it both now and/or in the future. Recording should be undertaken on the understanding that the information will be scanned and/or uploaded to Frameworki as soon as possible. The uploading should take place within 1 working day of the paper record being made. 3.2 Social care workers (or healthcare workers in integrated teams who are working on behalf of Adults Services) should ensure that they are as explicit as possible in writing case records, by either avoiding subjective terms or by offering an explanation where they are used. This is because the same term can have different meanings depending on who is using it. 3.3 It is expected practice that discussions and decisions made in professional supervision in relation to a customer are recorded on the customer s case record. Copyright 2014 West Sussex County Council / Version 3.3 / October 2014 Page 5

6 Case recording and document management: guidance 6 Security and confidentiality of paper records - reminder Ensure that members of the public cannot view any notes you have made about them or about other customers or carers whom you have visited earlier in the day. If visiting a customer in a public place, ensure that you are not discussing confidential matters or using identifying names where you may be overheard by others. Do not take papers concerning other customers with you on home visits as far as practicable: if unavoidable, leave them locked out of sight in your car. Do not leave hand-written case notes or template forms or pocketbooks unattended or lying around where anyone else can read them they contain information that should not be viewed or accessed by others. If you are working with handwritten notes whilst based in a county council building or at an NHS site, and you are away from the desk for some time, remember to make sure that the desk you are using is clear as this will enable another member of staff to use it if required. At the end of the working day clear away all files and personal belongings and lock them in your personal locker or take them home with you. If you take hand-written case notes or template forms or pocketbooks home with you, it is your responsibility to keep them safe at all times and to maintain confidentiality. Make sure that any handwritten notes are destroyed (use the confidential shredder if available) once the information has been transferred to the Frameworki record. 3.4 To be compliant with the Human Rights Act 1998, case recording should also: be written as soon as possible after an event has occurred; be brief and concise giving an account of work undertaken; be factual, consistent and accurate about the contacts made and services provided; include the customer s own contribution to assessments, plans, and review forms and other documentation - including disagreements or problems and their resolution; demonstrate the use of anti-discriminatory and anti-oppressive practice by using appropriate and respectful language when recording; be written in plain language without using jargon, irrelevant speculation, personal comments and discriminatory subjective statements; Copyright 2014 West Sussex County Council / Version 3.3 / October 2014 Page 6

7 Case recording and document management: guidance 7 Be clear in differentiating between opinion and fact (if opinions are to be recorded they should be identified as such and the reasons given for reaching them); state why a decision has been made and what evidence and/or advice has been considered in reaching the decision; and be signed and dated by the person making the entry. Lost or mislaid handwritten case records If you lose or mislay information - or have a near miss (for example, you remembered when you finished an appointment with a customer that you had left some handwritten notes or other papers behind so you went back straightaway and collected them) - you must report this to your line manager. Line managers will be expected to complete the corporate Security Incident checklist and send it to the corporate IT Policy and Planning Security lead officer based at County Hall. 4. Recording practice electronic records 4.1 Before creating an electronic record, social care staff (and healthcare staff where relevant) should always think about the purpose and content of the record and who may have access to it. Computer security and confidentiality - reminder Ensure that members of the public cannot view your computer screen. Do not move a desktop computer to a new location without gaining approval. Do not allow other members of staff to use your User Identification and password. Do not leave your computer (laptop or desktop) unattended without first ensuring that confidential information cannot be viewed or accessed by others. Close your computer down properly when you have finished each session. Make sure that you have collected all output from the printer and ensure that all documents are either stored securely or disposed of in a confidential manner. Copyright 2014 West Sussex County Council / Version 3.3 / October 2014 Page 7

8 Case recording and document management: guidance Care workers should ensure that they are as explicit as possible, by either avoiding subjective terms or by offering an explanation where they are used. This is because the same term can have different meanings depending on who is using it. 4.3 To be compliant with the Human Rights Act 1998, electronic case recording should also: be written as soon as possible after an event has occurred; be brief and concise giving an account of work undertaken; be factual, consistent and accurate about the contacts made and services provided; include the customer s own contribution to assessments, plans, and review forms and other documentation - including disagreements or problems and their resolution; demonstrate the use of anti-discriminatory and anti-oppressive practice by using appropriate and respectful language when recording; be written in plain language without using jargon, irrelevant speculation, personal comments and discriminatory subjective statements; Be clear in differentiating between opinion and fact (if opinions are to be recorded they should be identified as such and the reasons given for reaching them); state why a decision has been made and what evidence and/or advice has been considered in reaching the decision; and be signed and dated by the person making the entry. 5. Recording warnings on customer records 5.1 The latest guidance to staff on recording warning information on customer records should be accessed, read, and applied. The written guidance can be found on the internet (visit: westsussexconnecttosupport.org/professionalzone). 5.2 In particular, staff need to be extremely careful when recording Potentially Violent Person Warnings on Frameworki as some have been incorrectly recorded resulting in a serious breach of data quality. These must only be recorded for the person who is violent or potentially violent and not for their relatives. The alert function in Frameworki will send an automated red warning and an alert to the record of all those people linked to the subject. 5.3 To avoid warnings being used incorrectly and as a result, multiple alerts being generated with incorrect information being stored on the records of related people, only managers can now authorise the recording of warnings on Frameworki. Copyright 2014 West Sussex County Council / Version 3.3 / October 2014 Page 8

9 Case recording and document management: guidance 9 6. Storage of different types of records 6.1 In some circumstances it will be necessary to maintain a paper record in addition to a Frameworki record. Typically, these will be documents that have required a so-called wet signature. They are kept against the possibility of legal challenge. See the text box below for more information. Scanning and management of wet signature documents Documents with, for example, customer signatures signifying agreement or consent to share information should be scanned for general availability and kept in hard copy. This will ensure the highest level of integrity should the document be required in the event of legal challenge. (Courts do nevertheless accept scanned copies of original documents). Documents such as deeds, guarantees or certificates, which are not the property of the county council, can only be destroyed with the express written permission of the owner. Copies of such documents, when provided by the customer, can be scanned into Frameworki and the hard copy will then destroyed. This is in line with the advice in the British Standards Institution s BIP 0008 Code of Practice where it states that it is reasonably safe to destroy a document when its image has been captured and managed in accord with that Code of Practice. (BIP 0008 is a Code of Practice, originally introduced in 1996 and updated most recently in 2008, providing guidance to ensure, as far as possible, that electronic documents and scanned images are accepted as evidence by the courts. The process under which documents are managed is as important as the technology used: where a document is reproduced it has to accurately reproduce the contents of its original. For more information, visit: bsigroup.com/en-gb and use the search engine). 6.2 In cases where a paper record is kept there should be an entry on Frameworki on the customer s personal details screen, to identify the location of the record, and the person/team responsible for it. 6.3 In all other cases where a paper record is kept, such as in specialist day services, the case record needs to follow an agreed format and be in line with this guidance. Copyright 2014 West Sussex County Council / Version 3.3 / October 2014 Page 9

10 Case recording and document management: guidance Home (non-county council) computers can only be used for work purposes with the approval of line managers. If they are used, Documents should only be saved on an encrypted memory stick, supplied by the county council; Documents saved on an encrypted memory stick should be transferred to the main group network drive as soon as possible; All data from the memory stick should be deleted as soon as it has been transferred. 6.5 The West Sussex Deprivation of Liberty Safeguards Team is required to keep documentary records of all of its activity. These are kept on Frameworki as part of the customer record. Documents that require a wet signature (for example, copies of formal authorisations that have not been signed digitally) are routinely kept on the paper file. 6.6 Care homes operated by the county council, where one or more individual resident is subject to a Deprivation of Liberty Safeguards formal authorisation, are required to keep paper records of all activity relating to such decision-making under the Mental Capacity Act. These records need to be kept as part of the arrangements for compliance with Care Quality Commission requirements. 7. Information-sharing principles 7.1 This section of this guidance concerns information that is given by Adults Services to other people or agencies. It does not deal with a customer s access to information about his/her records. The latter is explained in detail in the Subject Access Policy Guidance available on the county council s website (visit: westsussex.gov.uk and type access to social care records in the search engine). 7.2 Adults Services has a duty to observe the confidentiality of customers, and there is an explicit requirement to obtain the consent of the user prior to information being shared with another agency or third party. 7.3 Telephone requests for access to customer data from other professionals should be challenged, and appropriate enquiries conducted to confirm the legitimacy of such enquiries. It should, however, be remembered that there is a responsibility to act where there are concerns of a safeguarding nature, and to share all relevant information for promoting the safety and well- being of a vulnerable person. A decision to share information in these circumstances should be proportionate to the presenting concern. Copyright 2014 West Sussex County Council / Version 3.3 / October 2014 Page 10

11 Case recording and document management: guidance We do not share information with a third party until we have established that the customer has given consent to share or that the person requesting information is doing so in a legal capacity, for example, has a Lasting Power of Attorney, for those who lack mental capacity to make specific decisions about their care. Information about the status of the third party should be found on Frameworki but if not further enquiries may be needed to establish the legitimacy of such enquiries. Our duty to treat a customer s information as confidential should be explained and any follow up enquiries should be completed in a timely manner so as not to add delay or cause undue distress. 7.5 If consent has not been obtained from the customer for the disclosure of information this can happen only if one or more of the following conditions apply: Adults Services has to disclose the information to ensure that it undertakes its statutory functions for example, in the gathering of information in an adult safeguarding investigation. The disclosure of information is legally necessary for the administration of justice for example, where a crime may have been committed. Disclosure is necessary to protect the person, for example if the person requires medical assessment and treatment, as they are mentally unwell. The customer does not have the capacity to consent, and arrangements have not been made to legally delegate this to another responsible adult or to a person holding a relevant Power of Attorney or who is acting on behalf of the Court of Protection: in these circumstances, it must be in the customer s best interests for the personal information to be shared. 8. Managers what you need to do 8.1 Managers have key responsibilities in relation to case recording and access to information. On a routine basis you should undertake the following activities in terms of case records: Check that your staff (including any healthcare workers acting on behalf of Adults Services in integrated or co-located teams) are following the guidance set out here as well as any other relevant guidance documents such as on information security and on document management; Check that your staff are familiar with where to find relevant guidance documents on the internet and are using them to inform their practice on case recording; Check that your staff are familiar with where to find the relevant user guidance for Frameworki; Assess and evaluate the quality of work with customers and carers through supervision, observation, planning and decision-making processes; Copyright 2014 West Sussex County Council / Version 3.3 / October 2014 Page 11

12 Case recording and document management: guidance 12 Ensure that discussions and decisions made in supervision are recorded on the customer s Frameworki case record, when indicated; Audit case records in line with the requirements periodically specified by the Adults Services Quality Assurance Management Board; and Identify any training needs of your staff in terms of case recording and access to information. Lost or missing paper case files Having been notified by the member of staff who has lost or mislaid sensitive records concerning a customer or carer, the line manager is expected to complete the corporate Security Incident checklist and send it to the corporate Policy and Planning Security lead officer (Shantha Dickinson). A process, internal to Adults Services, in relation to paper case files that have gone missing en-route to or from the corporate File Store, was published by the Adults Services Quality Assurance Management Board in December This is available online at westsussexconnecttosupport.org/professionalzone Copyright 2014 West Sussex County Council / Version 3.3 / October 2014 Page 12