A6 Flashcards
(37 cards)
What is NICE
National institute for health and care excellent
What is the purpose of NICE
provides guidelines and information on standards and effectiveness of care
What is MAR
A medicine administration record
What is the purpose of MAR
A medicine administration record that is updated every time any medication is given to a patient in a healthcare setting, contains a list of what has been administered and when. It can be paper or electronic based
Who has responsibility that records are kept in a timely manner
Every healthcare professional
Why is it important to record information in a timely way, as soon as possible
To make sure the information is accurate and not forgotten, ensuring nothing is missed
What dangers could occur if records regarding medication are not recorded
Someone may be given the incorrect amount or given the wrong medication which may lead to further sickness/harm or even death
An allergic reaction may occur
What should you do if you do not know how to correctly store information
Ask your supervisor
How can you ensure confidentiality/security is not compromised by leaving public places or data unprotected
Use passwords
Use privacy screens
Directly hand over information and do not leave them unsupervised
Why should you avoid abbreviations
They may be misunderstood as they may mean different things in different settings
What is an audit
An audit is when a review or inspection is carried out to ensure compliance with regulations, policies or legislation. It helps identify good practice
When record keeping, it is your responsibility to …
Ensure information is legible: if writing records by hand, others must be able to use it, in black pen
Ensure records have a date, time and signature
Use a signature rather than initials
Ensure care is taken to enter the data record accurately if using electronic systems
Why is it essential to collect information
To inform diagnosis, the type of treatment that may be required and anything which may impact their present health
Why is personal information stored
So it can be shared as appropriate with different healthcare professionals
For future use
What is GDPR
Data protection regulation 2018
What year is GDPR
2018
What is GDPR
A set of data protection rules
What are the 7 principles of GDPR
1) lawfullness, fairness and transparency, people have the right to know and view any information held about them
2) purpose limitation: information should only be collected for specific purposes
3) data minimisation: data collection should be limited to that which is necessary and relevant to the purpose
4) accuracy: inaccurate data should be destroyed or recollected
5) storage limitation: information shoudnt be kept longer than necessary
6) integrity and confidentiality: information should be held and processed securely, access should be restricted for non authorised staff
7) accountability: appropriate systems and records should be in place to demonstrate they’re complying with data protection regulations
What rights does GDPR outline
Right to be informed
Right of access
Right to rectification
Right to erasure
Right to restrict processing
Right to data portability
Right to object
Rights related to automated decisions making including profiling
What do the Caldicott principles ensure
That confidential information is protected and used appropriately
What are the 8 caldicott principles
1) justify the purpose for using confidential info
2) use confidential info only when necessary
3) use the minimum necessary confidential info
4) access to personal confidential information data should be on a need to know basis
5) everyone with access to confidential info should be aware of their responsibilities
6) comply with the law
7) duty to share for individual care is as important as the duty to protect patient confidentiality
8) inform patients and service users about how their personal confidential information is used
What is client history and what are the examples of it
Factual information about a person e.g. name, date of birth, nhs or national insurance number
What does PRN mean
Pro re nata
‘Given as needed’
What does BP mean
Blood pressure
