K117 Enhancing your healthcare practice Unit 14 Interpreting and managing information Copyright © 2013 The Open University Contents Unit 14 Interpreting and managing information 2 14.1 Information about service users 2 14.2 Interpreting information 13 14.3 Safeguarding information 16 14.4 The development of users’ records 21 Unit 14 summary 23 References 24 Acknowledgements 25 Unit 14 Interpreting and managing information Copyright © Iurli Sokolov/iStockphoto In your practice setting, you are exposed to a range of data that you need to interpret or understand, in order to have the best possible information available to inform your practice. This, together with evidence (as explored in Unit 13), can then make practice become best possible practice, providing, of course, that a person-centred approach is adopted. While you are in your practice setting, you will come across a range of information that is relevant to your practice. This unit deals with government legislation, service users’ records, organisations’ protocols, and guidelines for employees. The aim is to enable you to understand and effectively manage the data that you have access to from a range of sources. The unit explores the significance of data relating to service users, and addresses security, confidentiality, access to records, record retention and use of multidisciplinary records. There is a range of Acts, national government codes of practice and guidelines, and organisational policy documents and processes available to inform the management of data, which is often very detailed. If you access national documents you are advised to be selective in what you read, focusing on the section that has particular relevance to the aspect of data management you are studying or needing to access to inform your practice. A useful source of information that is more easily understood is information provided to service users about the management of their records. The principles of: l legible and accurate recording of data l maintenance of confidentiality l safe storage l safe disposal apply to all records used by service providers for whatever purpose. 14.1 Information about service users As a practitioner in health and social care, you are required to contribute effectively to the collection and interpretation of data in your practice setting. Activity 14.1 is designed to help you consider what user-related information is handled in your practice setting. Unit 14 Interpreting and managing information 2 of 25 Monday 8 February 2016 Copyright © Denise Hager, Catchlight Visual Services/Alamy, Copyright © Paul Doyle/Alamy Activity 14.1 What types of information do I use? Allow 30 minutes First of all consider what information about service users you handle or need. This is not purely about information as evidence, which you studied in Unit 13, but about all the information that enables practitioners to meet the needs of service users in a person-centred way. This could, for instance involve numerical data, dates, reminders, descriptions or instructions. Note down the different types of information that you think of – you should consider information available from service users, carers, policy documents, charts, department records, and minutes/notes from meetings. Provide your answer… Discussion Your list might have included a lot of different pieces of information, including some of the following: l the personal details of service users l the date when an episode of care or support began l the details of assessments l the result of a specific test, assessment or investigation l plans of care l evaluations of the success of interventions l the date, time and duration of a visit to a person at home l a programme of rehabilitation exercises to be completed by a service user l a list of activities a person with learning disabilities participated in during attendance at a day centre Unit 14 Interpreting and managing information 3 of 25 Monday 8 February 2016 l a list of the dates by which a child achieved pre-determined steps in a selfmanagement teaching programme l a record of attendances at therapy sessions for a person with mental health issues l a record of the visits made by another agency to a specific individual and the assessment reports made at that time l a letter of referral to another service or agency l a letter from one service/agency to another providing an update on their interventions and their outcomes l the date when an episode of care ended l case conference records l notes from team meetings. You probably found that your list contained items that are necessary in order for your service to provide the best possible interventions for service users. You will also be aware of the importance of keeping clear records so that the information can be shared with and interpreted by others. Information recorded by all members of a team is essential to the maintenance of high-quality care. Record keeping The Department of Health published a NHS code of practice for records management (Department of Health, 2006) and included a list of types of information which would be considered to be health records (p.1): l patient health records (electronic or paper-based, including those concerning all specialties, and GP medical records) l records of private patients seen on NHS premises* l Accident & Emergency, birth, and all other registers l theatre registers and minor operations (and other related) registers l administrative records (including, for example, personnel, estates, financial and accounting records; notes associated with complaint-handling) l X-ray and imaging reports, output and images l photographs, slides, and other images l microform (i.e. microfiche/microfilm) l audio and video tapes, cassettes, CD-ROM, etc. l emails l computerised records l scanned records l text messages (both outgoing from the NHS and incoming from service users). *The Department of Health advises that although technically exempt from the Public Records Act it would be appropriate for NHS organisations to treat such records as if they were not exempt. Unit 14 Interpreting and managing information 4 of 25 Monday 8 February 2016 This list recognises that records may be paper-based or electronic. The record may contain information about the current episode of care only, or may be a compilation of every episode of care for that individual. The Department of Health is essentially stating that any information held about service users and any medium used to provide data about the service user is subject to the Public Records Act 1958 sections 3(1)–(2). The Scottish Government (2010) has also published guidance entitled, ‘Records Management NHS Code of Practice’. This guidance is informed by that published by the Department of Health in 2006. The types of records you encounter will depend on the type of services your organisation provides, but it is important to access all relevant information about a person to ensure your interactions and interventions with individual service users are genuinely personcentred. The different sorts of records include: l departmental notes l profession-specific information: supplied by medical, nursing, physiotherapy, occupational therapy, speech therapy staff, and so on l data, for example X-rays and results of other diagnostic tests. Record keeping is a legal requirement and where relevant a professional requirement for all those working in a health or social care setting. It requires a number of skills, including being able to identify what to record and the use of appropriate language. If notes are not kept a number of issues can result: l Regardless of how good your memory is, it is impossible to hold in your head all the information about all the service users you work with. l If you do not record information and you are not available, another practitioner or a carer will be unable to follow the agreed plan of care. l If you do not record or pass on information about a service user, they could be endangered by receiving an inappropriate intervention. l If you do not record or pass on information about a service user, there will be no or limited information to inform the interventions with this person. l Not maintaining a system of recording would cause difficulties in respect of any possible legal proceedings, for instance allegations of negligence. The need for accuracy It is important for service users’ records to be objective and accurate. The fictional case of Tracey in Box 14.1 shows what can happen if misleading labels are given through lack of accuracy and objectivity in record-making practice. Box 14.1 Tracey’s notes Tracey is two years old and has Down’s syndrome. She has attended a child health centre on a number of occasions over the past 12 months due to her failure to gain weight. Her records comprise a great many notes recording her attendances. On the front page of the notes a doctor recorded, ‘This child’s mother is over-anxious, the child is just a little underweight for her age.’ On the second page a social worker wrote, ‘Obvious signs of failure to thrive’. Unit 14 Interpreting and managing information 5 of 25 Monday 8 February 2016 Later in the notes someone (signature and designation not given) said, ‘Signs of malnourishment.’ The rest of the sentence was illegible. Finally, on her most recent visit to the centre Tracey was seen by a different doctor, who wrote, ‘Persistent failure to gain weight refer to paediatric dietician’. The dietician assessed Tracey including a full history from birth. During the discussion about Tracey’s feeding pattern and dietary intake her mother shared Tracey had a voracious appetite although as a baby she had some difficulty swallowing. Her general practitioner had advised her to thicken Tracey’s feeds with ‘Horlicks’ so Tracey’s milk feeds had been thickened with Horlicks from 2 months of age. The dietician recorded in Tracey’s notes, ‘As there is an increased incidence of coeliac disease in children who have Down’s syndrome and Tracey has been exposed to a wheat-based product since aged 2 months I would recommend screening for coeliac disease.’ The following record stated, ‘Screening for coeliac disease positive, commence gluten-free diet and refer back to paediatric dietician to provide information, support and advice to Tracey’s parents.’ Filed inconspicuously at the back of the notes was a letter from a social worker stating that there were no concerns regarding parenting and that Tracey’s condition was not related to over anxiety in her mother. Tracey’s care was compromised by the doctor stating that her mother was over-anxious and that Tracey was only a little underweight. Others noted her failure to thrive, however, according to the records did not take action to establish the cause of the problem. Every time Tracey attended the health centre, practitioners who read the notes fell into the trap of trusting the information on the front page and were biased by it. However, the judgements of the latest doctor and the dietician were made independently of the bias of the previous records. By performing a considered, objective assessment of all the data available, including listening to Tracey’s mother, they were able to establish that Tracey’s presenting signs and symptoms were due to a specific physical cause rather than over anxiety in her mother. If you would like to know more about Down’s syndrome and coeliac disease your may wish to access the sites of the Down’s Syndrome Association and Coeliac UK. The activities in this section are aimed at helping you to keep accurate and appropriate records and to consider how records can be interpreted. The next step is to recognise the features of accurate and appropriate records in relation to policy requirements. Activity 14.2 Accurate and appropriate records Allow 30 minutes Box 14.2 Record keeping best practice Patient records should: Be factual, consistent and accurate Unit 14 Interpreting and managing information 6 of 25 Monday 8 February 2016 l be written as soon as possible after an event has occurred, providing current information on the care and condition of the patient; l be written clearly, legibly and in such a manner that they cannot be erased; l be written in such a manner that any alterations or additions are dated, timed and signed in such a way that the original entry can still be read clearly; l be accurately dated, timed and signed or otherwise identified, with the name of the author being printed alongside the first entry; l be readable on any photocopies; l be written, wherever applicable, with the involvement of the patient or carer; l be clear, unambiguous, (preferably concise) and written in terms that the patient can understand. Abbreviations, if used, should follow common conventions; l be consecutive; l (for electronic records) use standard coding techniques and protocols; l be written so as to be compliant with the Race Relations Act and the Disability Discrimination Act. Be relevant and useful l identify problems that have arisen and the action taken to rectify them; l provide evidence of the care planned, the decisions made, the care delivered and the information shared; l provide evidence of actions agreed with the patient (including consent to treatment and/or consent to disclose information). And include l medical observations: examinations, tests, diagnoses, prognoses, prescriptions and other treatments; l relevant disclosures by the patient – pertinent to understanding cause or effecting cure/treatment; l facts presented to the patient; l correspondence from the patient or other parties. Patient records should not include l unnecessary abbreviations or jargon; l meaningless phrases, irrelevant speculation or offensive subjective statements; l Irrelevant personal opinions regarding the patient. Department of Health, 2003, p. 17 Look at the list in Box 14.2, which is from the NHS Code of Practice on confidentiality, issued in November 2003, and which at the time of writing (October 2011) has not been superseded. Unit 14 Interpreting and managing information 7 of 25 Monday 8 February 2016 Identify which elements of ‘best practice’ were followed or not followed in the case of Tracey. Also make a note of anything on the list that raises questions for you in your own practice setting. Discussion In Tracey’s notes the first entry, by the doctor, might be considered to be an ‘offensive subjective statement’. The later note, relating to the ‘Signs of malnourishment’, is more difficult to tackle, but has a subjective and speculative tone. There is little evidence of dialogue with Tracey or her mother until the last few entries in the notes. There is also an issue of legibility. It possibly struck you that there is a lot in the resource to take into consideration for your own practice, and that it would be easy to miss some of these measures. For example, if notes have to be consecutive it would be good practice to number the pages, but this is something that practitioners might forget to do. You might have concerns about the quality of handwriting in some records, or about the reference in the resource to ‘unnecessary abbreviations’. The resource might also have made you think about whether notes should make more acknowledgement of any dialogue with service users – that is, information given and received, or negotiated. When you are involved in health and social care, it is your responsibility to ensure that the following are recorded: l all attendance and non-attendance for, and any refusal of, treatment l all advice given and interventions completed l any interventions not completed and the reason why l details of any contacts made via telephone or email l identification of all those involved with a particular service user during each intervention. You must ensure that your manager holds a record of your signature, initials and forwarding address to facilitate the interpretation of records in later years if necessary. You must also ensure that you date and sign both the records and a register of service users, if one is held. A method of identifying practitioners who contribute to electronically held records must be in place. Consideration would also need to be given to the requirements of any act, for example the Equality Act (2010) which superseded the Disability Discrimin
ation Act (2005) and the Race Relations Act (2000). You will need to refer to the list above while completing the following activity. Unit 14 Interpreting and managing information 8 of 25 Monday 8 February 2016 Finding out what is in a record Southern Health and Social Care Trust (2010) Patient Centred Care Record, Copyright © Southern Health and Care Trust Activity 14.3 Finding out what is in a record Allow 1 hour Access the records of a person using your service (a service user whose records you normally have access to). If you don’t normally have access to service user records, you will need to seek the support of your supervisor to access a service user’s records under their direct supervision. Identify where in these records you would find the items. Unit 14 Interpreting and managing information 9 of 25 Monday 8 February 2016 Do not record anything that could identify the service user, your colleagues or your organisation. Make a note of anything that makes this task difficult. We have created a Word document containing the table if you wish to fill it in electronically. Item for recording Location of record Notes Record of attendance Record of non-attendance Any refusal of treatment Advice given Interventions completed Details of any contacts made via telephone, email, etc. Identification of all those involved with a particular service user during each intervention Discussion The absence of any particular item of information may mean either that there is nothing to record, or that something has been omitted. In the example of Tracey’s notes, the omissions might have related to the reason for previous attendances: failure to gain weight. If the record is in paper form, the handwriting may be difficult to read, or the record may have suffered some physical loss or damage. It can be dangerous to draw conclusions from just one section of a written record. Tracey’s example shows that you need to read right through the notes to be fully aware of the situation. Her notes also included an unsigned and partly illegible entry. It was not clear who had written ‘signs of malnutrition’, or what the rest of the sentence said – it may well have said ‘possibly due to a malabsorption issue’. If the signature had been clear it would have been possible for others to discuss what had been written with the practitioner concerned. You might also have found that it was not always clear where to look. A number of different people may be delegated to file the notes relating to one individual at different times, resulting in inconsistent and impractical ordering of information. As the responsibility of record keeping is not the responsibility of one person, it is highly likely that unsecured or temporarily filed material may get lost. The loss will not necessarily be noticed by subsequent users. In Tracey’s case notes, there was a report from a social worker stating that her condition was not related to parenting and her mother was not overly anxious. Had this report been seen by those who subsequently read the notes, they might have been more inclined to seek out another cause of Tracey’s problems. When you look at service users’ records, you often distinguish between the different practitioners who have made entries – you may interpret what is written according to the role occupied by the practitioner who wrote it. The doctor who made the original comment about Tracey’s mother being over anxious is likely to have carried a greater level of authority than other practitioners in the multidisciplinary team. Perhaps the Unit 14 Interpreting and managing information 10 of 25 Monday 8 February 2016 social worker who wrote the letter saying that there were no concerns over parenting was not known to the team, or was overruled in some way by others with greater authority, resulting in the letter not being given sufficient acknowledgement. Perhaps the letter was simply filed in a rush, without the information being given the attention it deserved. In another scenario, the social worker’s assessment might have carried more weight and this letter would have been treated as crucial, ‘not-to-be-missed’ information. In the hustle and bustle of practice, or during a crisis, it can be challenging to reserve time for making records. Strong managerial leadership can be key to maintaining standards. In Activity 14.4, you consider Gareth’s position and the potential for mistakes. Unit 14 Interpreting and managing information 11 of 25 Monday 8 February 2016 Records as part of an intervention Southern Health and Social Care Trust (2010) Patient Centred Care Record, Copyright © Southern Health and Care Trust Activity 14.4 Records as part of an intervention Allow 30 minutes Read the scenario below and note the potential for mistakes in service users’ records. Identify where the responsibility lies. Unit 14 Interpreting and managing information 12 of 25 Monday 8 February 2016 Gareth writes up his contact with service users in the multidisciplinary notes. He usually does this each day, but if he forgets or if time is short he writes his notes the next morning instead. Gareth believes that contact with service users is more important than writing notes. His writing is not clear, but then neither is that of other staff. There is no standard system of note writing – each member of staff uses their own method. Discussion By leaving note writing to the next day, the accuracy of the information can be compromised. Information written at a later date may not be an accurate representation of what happened. Moreover, if Gareth goes home without making a record, he is effectively withholding information – as he is not available to share information with colleagues/other agencies and there are no records available to them to inform interventions. Contact with a service user should not be considered complete until the notes are written, thus making note writing an integral part of an intervention. The notes should be completed after each person has been seen. If this is not possible, then they should be written as soon as possible thereafter and at the very latest before ‘going off duty’. Gareth is responsible for keeping records appropriately. He needs to be sure that his writing is legible. If the notes cannot be read, they will not be helpful to others accessing them. He also needs to seek advice regarding his note-writing skills, and possibly access in-service training. The manager of the department is responsible for ensuring that all staff follow an approved system of record keeping in accordance with professional, organisational and legal guidelines. Service users’ notes are a formal document and must be written as such. When considering service users’ records, it is sensible to think and question beyond what you see. Records can raise questions. What is not recorded? How objective are the comments? How person-centred is the practice reflected in a record? Tracey’s notes did not seem to put her and her family at the centre of her care. The department where Gareth worked did not seem to have any system in place to support good record-keeping practice. How you interpret the information held within records depends on what questions you ask. 14.2 Interpreting information At every level in your organisation, decisions are made about what is important, what needs action, what needs passing on to colleagues, what is not to be taken forward. It is easy to feel as though you are suffering from information overload. It is important, therefore, to be able to make judgements about the meaning and importance of the information you are handling. Interpreting numerical data Numerical data can be presented in a range of ways. For example in tables, line graphs, bar charts, pie charts and scatter diagrams. Using these devices to organise numerical data can help practitioners make sense of statistics to describe the relationships between Unit 14 Interpreting and managing information 13 of 25 Monday 8 February 2016 people or groups and other factors. They can also be used to facilitate the recognition of emergent patterns and to see trends. For instance, you can scan across information in the rows and columns of a table to search for ‘blips’ and trends. In the case of Tracey, practitioners had expressed concern about malnourishment and failure to gain weight, so plotting her weight and height on a percentile chart (as in this example from the World Health Organization) would have clearly demonstrated whether she was underweight for her gender, age and height, and whether there was an emerging trend. Further, if Tracey’s mother had been asked to keep a dietary record of amounts and types of food and fluids Tracey had over a period of time, the team expressing concerns about her wellbeing would have seen that Tracey ate extremely well, and that therefore there was likely to be an underlying cause for her not gaining weight as they felt she should. To understand the significance of data, you also need to understand something about how the information was gathered. If you were aware that there was the potential for mistakes or inaccuracies in the data collection process, you would be more cautious and more questioning of the results. So you need to be sure how the data was gathered. If Tracey is weighed and measured, for example, there are correct ways of going about it in order to obtain the most accurate data possible. The weighing scales need to be correctly calibrated; it needs to be clear whether her weight is to be recorded with or without clothing; the correct technique is required to measure her height accurately, and so on. Activity 14.5 Interpreting numerical data in practice Allow 45 minutes Consider one type of numerical data that is recorded in relation to service users who access your service. This could be a physical measurement (such as height and weight), physiological (such as blood pressure or breathing rate), psychological (such as mood score), the number of times something happens, or any other relevant information. Answer the following questions: l Are there any recognised limitations to accuracy? l What precautions are followed to ensure the data is collected accurately? l How is the data recorded? l What device (if any) is used to help interpret the data? You might need to track changes over time, changes in response to interventions, or compare the data with ‘normal’ values. Discussion Tracey’s situation is used here to illustrate the points, but your results might look very different. Tracey’s height and weight would be measured according to an agreed protocol which means that community-based practitioners, such as the health visitor, who visit Tracey at home, and practitioners in the health centre would all follow the same protocol for removing clothing, being cautious to be culturally sensitive and maintaining Tracey’s privacy and dignity. They would also calibrate the equipment and get her to stand up straight. However, they would be unable to compensate for any variation in the weighing scales in the two settings, as they are likely to be different makes and designs. In each setting, however, it should be noted which scales had been used the first time her weight was recorded so the same scales were used Unit 14 Interpreting and managing information 14 of 25 Monday 8 February 2016 subsequently. Any factors which could affect measurements, for instance Tracey finding it difficult to stand up straight, would also be recorded. By recording factors which influence the accuracy of the data, the practitioner ensures that anyone reading the results at a later date could be mindful of the limits to the accuracy of the data. Tracey’s data would be plotted on two graphs specific to her gender, one of age against height and one of age against weight. Thus changes would be plotted at each appointment. The graphs also show the normal range of height and weight in the population by age, allowing comparison with children of the same age. There is an example of a BMI percentile chart on page 2 of the World Health Organization’s percentile chart which you looked at earlier in this section. Shaded areas either side of the ‘average’ indicate the normal range. BMI measurement and monitoring is a more accurate measure of the appropriateness and health implications of a person’s weight against gender, height and age. You saw in Activity 14.4 that protocols and guidelines are important to ensure that data is collected in an accurate way. It is also important to be aware of limitations when interpreting such data. Guidelines serve to ensure that the information collected is stored and handled appropriately. Interpreting guidelines Local guidelines, organisation policies and departmental protocols cover a range of activity. Much of what practitioners discover about local practice is passed on by word of mouth or by observing what others do. However, it is best practice to follow up any wordof-mouth information by seeking out the documented standards and guidance in order to confirm your adherence to agreed protocols. Consider record-keeping practice with this in mind. Activity 14.6 Exploring local practice in record keeping Allow 2 hours Explore record-keeping practice in your department or organisation by speaking with senior colleagues and checking policies and guidelines relevant to your practice. It may be helpful here to refer to Resource 14.1: Collecting verbal information. Consider: l the method or model of note keeping you use (one example is problem-orientated health records) l how long records are retained l what reference is made to national and professional guidelines or to other external sources. Discussion The way notes are written can be significant when it comes to interpreting the records, as this can help you to understand the particular perspective presented by a particular Unit 14 Interpreting and managing information 15 of 25 Monday 8 February 2016 discipline. However, notes written from the perspective of one discipline are selflimiting as they do not incorporate all the information from other sources. Statutory/professional bodies set standards for record keeping. Your organisation might draw on guidance from professional/statutory bodies, the Department of Health or national organisations. Records should be disposed of as soon as possible, subject to national and local retention periods. Most service user records are kept for approximately eight years after the last entry, but sometimes the required period is longer. Maternity records are retained for a minimum of 25 years after the birth of the last child; mental health records for 20 years or 10 years after the person’s death if sooner; children’s and young people’s health records until the person’s 25th birthday or 26th birthday if the young person was 17 when the last entry was made (Department of Health, 2009). Local policies and guidelines have been designed to be followed by the local workforce, and as such relate to local structures and responsibilities. However, as pointed out in the last activity, local policy is steered by national and professional agendas. 14.3 Safeguarding information National and devolved governments issue regular information intended to ensure that people receive the best possible care through a framework for good practice. Much of this is contained within legislation. There is a range of government initiatives linked to the management of information, aimed at assuring people’s privacy and rights. All these initiatives have an impact on the records you keep about people accessing your service. Consider data protection and human rights. The Data Protection Act (1998) is about the rights and freedom of living individuals. It lays down conditions for the fair and lawful processing of personal data and particularly sensitive personal data. It is worthy of note that the Act does not protect the deceased. Access to the health records of a deceased person is governed by the Access to Health Records Act (1990). Under the 1990 Act an application for access to a health record of someone who has died can be made by the patient’s personal representative and any person who may have a claim arising out of the patient’s death. The Human Rights Act (1998) embeds fundamental rights as set out in the European Convention on Human Rights, which has bee