Record Keeping and Confidentiality in Health and Social Care

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Record keeping and confidentiality Increasingly, service providers are expected to keep records of interventions with clients. While this can seem time-consuming and arduous, good record keeping is key to an effective service, and can help in monitoring and improvement of your service delivery. Records can also help you in obtaining funding - they are a way of demonstrating the work you do and the successes you have. This chapter will help you think about your record keeping process and consider important aspects such as confidentiality, knowledge management and the Data Protection Act. Minimum Standards • The provider has policies and procedures for handling information about clients, including confidentiality and data protection • Record keeping systems are maintained and regularly monitored • Staff are trained in the operation of recording systems and understand the scope of their authority to access information • Staff understand and work in line with the requirements of the Data Protection Act • Clients are aware of their rights to access information and are enabled to exercise these rights • There are policies and procedures for sharing information with external agencies and clients are made aware of this on admission. • Records are written in a clear, concise and impartial manner and are dated and signed by the author • Statistical data is made available to inform development of local homelessness strategy Introduction Most service providers keep records in order to: • manage the daily operation of their projects • provide better support to clients • inform the project’s longer term development Increasingly, recording statistical information about your clients and services is necessary to
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