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STAFF BRIEFING

An overview of essential processes and policies

This document contains

1) An overview of the key points within essential processes and policies2) Useful contacts for each area3) Signposts to additional policy information on the intranet

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Question 2 : Are they effective?

• Consent• Information Governance• Records Management• Documentation • Accessing Policies

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Consent• Patients have a fundamental legal and ethical right to determine what happens to their

own bodies. Valid consent to treatment is therefore absolutely central in all forms of healthcare

• Consent is a patient’s agreement for a health professional to provide care. Consent can be given expressly i.e. in writing or orally, or may be implied e.g.. when a patient presents his arm for blood or pulse to be taken

• Valid consent: For the consent to be valid, the patient must:• have capacity to consent (see slides on the Mental Capacity Act in the safety

section)• have received sufficient information about treatment options, consequences and

risks; and• not be acting under influence of others

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ConsentDocumentation

• It is rarely a legal requirement to seek written consent, but it is good practice to do so for all significant procedures eg. where the treatment/procedure is complex or involves significant risks (‘risk’ may refer to adverse outcome, including ‘side-effects’ or ‘complications’), or where the procedure involves general anaesthetic or sedation

• For such procedures, it is essential to document clearly both a patient’s agreement to the intervention and the discussions which led up to that agreement; and also the type and version control of the information leaflets that are given to the patient.

• This may be done either through the use of a consent form or through documenting in the patient’s notes that they have given oral consent.

• Consent is often wrongly equated with a patient’s signature on a consent form. A signature on a form is evidence that the patient has given consent, but is not proof of valid consent.

• Patients may withdraw consent at any time – a signature on a consent form is not a binding contract!

• Completed forms should be kept with the patient’s notes.

• It is not usually necessary to document a patient’s consent to routine and low risk procedures, such as providing personal care or taking a blood sample unless there is reason to believe that the consent may be disputed later.

• It is always good practice to check that a patient is happy for you to give them treatment before you start.

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Consent Capacity• Valid consent can only be given by someone with the mental capacity to be able to consent.

• Adults (18+) - are presumed to have capacity to consent, unless the contrary is shown

• 16 / 17 year olds - For the purpose of consenting to treatment, minors aged 16 and 17 are treated as adults (but their refusal is not binding, and can be overriden by someone with parental responsibility)

• Children under 16 - can give consent if they have sufficient understanding and intelligence – i.e. Gillick competent (but they cannot refuse treatment). They must be able to understand fully the intervention proposed and the consequences. Healthcare professionals should always encourage the child to inform those with parental responsibility.

• Where a child is not Gillick competent, consent may be obtained from someone with parental responsibility.

• Patients who lack capacity - the Mental Capacity Act 2005 governs decision-making on behalf of patients (16+) who lack the mental capacity (either temporarily or permanently) to give or withhold consent for themselves. (see slides on the Mental Capacity Act in the safety section)

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Information Governance

What is Information Governance?

• Information Governance is a complicated way of saying: “anything you do with information” • i.e. creating, using and ultimately destroying or archiving information - securely, legally and

efficiently.

• or more formally:• “The management of all information from creation to destruction”

What is “personal data”?• The formal definition of personal data is: “Data which relates to a living individual who can

be identified from the data or from that data and other information which is likely to become available.”

• So any information that can identify an individual e.g. name, NHS number, hospital number, staff number, address etc., is personal data. You also have to be careful with combinations of data e.g. address and date of birth – this data could possibly identify an individual at an address.

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Information Governance

• Patients trust us to keep their information safe and that trust is vital for us to provide a safe and caring service

• You can share patient data with staff who have a direct involvement with the patient’s care

• If you have the patient’s consent then you can share with other people, but the patient must understand the implications of this sharing and have the option to stop the sharing at any point

• Never be bullied into releasing information, no matter how “important” the person asking for the information is

• If you don’t feel confident about sharing, or not sharing, information, always check with senior staff or the Information Governance manager on ext 3404

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Information GovernanceCaldicott Guardian• Every trust has a board level Caldicott Guardian responsible for information confidentiality, ours is

the Medical Director Dr Ros Given Wilson (ext 2958).

• Every trust also has a SIRO (Senior Information Risk Owner) .The SIRO is responsible for the risk to all information in the Trust – our SIRO is the Director of Finance, Performance & Informatics Steve Bolam (ext 4747)

• The Caldicott Principles: A set of basic rules on what to think about when using confidential information

• Justify the purpose(s) • Don’t use personal confidential data unless it is absolutely necessary• Use the minimum necessary personal confidential data • Access to personal confidential data should be on a strict need-to-know basis • Everyone with access to personal confidential data should be aware of their responsibilities • Comply with the law • The duty to share information can be as important as the duty to protect patient

confidentiality.

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Documentation - top 10 tips • Confidentiality – medical notes are ideally kept in a locked cabinet. If notes are not in a locked cabinet, they

should be kept in a cabinet in a locked room or somewhere they can be observed.• Do not leave records on paper or computer screens where they might be seen by unauthorised staff or

members of the public.• Smartcards or passwords to access information must not be shared.• All patients must have a care plan - pre printed care plans are acceptable as long as they are individualised

–which they have seen, consented to and signed. Care plans must be regularly reviewed and there should be documented evidence that this has occurred.

• Ensure all relevant nursing documentation is organised and included in the patients file and is completed accurately. This includes such variety as next of kin details, allergies recorded on the medication chart and evidence that all risk assessments have been completed on admission and updated on a weekly basis or if the patient’s condition changes.

• Observations should be taken as required throughout the 24 hour period and an accurate early warning score should be clearly recorded (all staff to ensure they read the policy). If you wish to raise a concern to another professional use the SBAR guide (situation, background, assessment and recommendation) to structure your conversation.

• All entries to records should be signed – Name, job title, date and time should be recorded. Handwriting should be legible.

• Good record keeping is an effective communication tool. During any handover, staff should be able to understand what has happened to a patient / group of patients and have adequate information to plan their nursing activity for the rest of the day.

• Do not include unnecessary abbreviations, jargon, or speculation. Identify the care delivered, potential risks or problems and show the actions taken to deal with them.

• Do not amend records without signing and dating the amendment.

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Documentation

• Good record keeping is an integral part of practice and is essential to the provision of safe and effective care.

• It has many important functions including a range of clinical, administrative and educational uses which include helping to improve accountability, showing how decisions relating to patient care were made.

• It helps to identify risks in order to enable early detection of complications and provides documentary evidence of services delivered.

• You must record your work clearly, accurately and legibly at the same time as the events you are recording as soon as possible afterwards.

• Clinical records should include relevant clinical findings, the decisions made, the information given to patients and any drugs prescribed or any other investigation or treatment

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Records Management• The trust and our patients rely on accurate and up to date records.

• Always check the identity of the patient matches the record. If the patient is present always ask the patient to confirm their details. The correct way to ask is e.g. "Could you tell me your address please" not "Do you still live at……". The patient should give you the information, not the other way round.

• If searching for a patient on Cerner Millennium or RIO be absolutely certain that you have correctly searched the PDS [the national spine] not just the local record. The Spine holds the most recent and accurate patient demographics. The local record could be years out of date.

• Make sure you track the patient records on the system to where you have taken them.

• Keep hardcopy records in a safe place. Make sure they cannot be accessed by anyone who does not have the right to see them.

• Don’t leave medical records lying about, always return them to the notes trolley (which should ideally be locked away or at least in a place where it is under constant observation)

• If sensitive hardcopy information needs to be destroyed, always use the trust’s confidential waste bags [blue] or shredders – before destroying records always check with your manger about record retention rules.

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Records management“You are your password”

• Remember the computer systems think the password is you; anything done on your password or smartcard will be traced back to you.

• Always log out of a computer or application when you’ve finished with it – so that the next user cannot use your access rights or access your patients’ records.

• Never share your password or smartcard with anyone.

• If you suspect that someone knows your password, change it immediately.

• Any trust computer hardware must be disposed of through the IT dept.

• Never use your own computer equipment [tablets, phones, laptops, home computers] to store patient data [words or images] unless you have checked with the IG manager first.

• All data on Trust systems belongs to the Trust and will be accessed by the Trust if there is a business reason to do so.

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Accessing policiesAll policy documents are available via the intranet

They can be accessed via the homepage by selecting Procedural Documents

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Accessing policies

For more information contact the corporate affairs manager on ext 4699 – check job title – think its Ext 1158

Policies are divided in to five key areas

• Patient related

• Staff related

• Corporate and IT

• Major incident

• Health and Safety

• Community Services