Core A - A6 (Managing Personal Information) Flashcards
(16 cards)
1
Q
Role in Record Keeping
A
- record interactions
- being competent with systems
- keep data confidential
- record must be factual
- use common abbreviations
2
Q
Role in Audits
A
- black pen and clearly written
- dated, timed and signed
- enter data correctly into systems
3
Q
Why is Information Collected
A
- patient history
- diagnosis
- treatment
- follow up care
4
Q
Why is Information Stored
A
- shared with other MDTs
- legal requirements
- patients rights in data
5
Q
Why is Information Protected
A
- data protection laws
- information governance rules
6
Q
Information Needed in Patient History
A
- name, DOB, NHS/hospital number
- P/C and history
- medication
- family history
- social history and care
7
Q
Why We Use Abbreviations
A
- save time
- standardisation
8
Q
Common Abbreviations
A
- PRN, as needed
- MAR, medication administration record
- BP, DNR, MST, NEWS2, PEWS
9
Q
The Reporting System
A
- preventing errors
- fast reporting
- easy access to information tracking
10
Q
When to Share Information
A
- diagnosis and care needs
- research and improving practice
- new innovations
- risk, crime, safeguarding
11
Q
Considerations When Sharing Information
A
- caldicott principles
- use of NHS number
- consent
- audience, reason and advocate?
12
Q
Formats for Sharing Information
A
- oral
- written
- forms
- presentations
- graphs/tables
- leaflets/posters
13
Q
Reasons for Recording Keeping
A
- full medical history
- helps professionals
- continuity of care
- legal protection
14
Q
Record Keeping - Contribution to Care
A
- quality of care across services
- log steps and decisions
15
Q
Responsibilities of Workers
A
- follow law and regulations
- act with honesty and integrity
- help with investigations
16
Q
Escalate Concerns When…
A
- safeguarding issue
- need to whistleblow
- radicalisation concern
