In this essay I am going to write on issues of confidentiality and record keeping. Nurses are subject to ethical, legal and professional duties which are considered to be to respect patient’s confidentiality. I will discuss about a nursing home staff that turned up on the ward to collect some personal documents that belongs to a discharged patient from the ward. Griffith and Tengnah (2008) “states that maintaining confidentiality of patient’s information is a fundamental element of professional conduct and ethical practice for nurses”.
The reason why I chose this incident is to explore the professional components of the incident that occurred during my clinical placement and to see how patient’s information can be maintained and the importance of record keeping. Patients’ information is identifiable because of their name, date of birth, address and postcode. A nurse must ensure that all confidential information obtained concerning patients must be protected and disclose only with patient’s consent (Rumbold, 2006). In order to respect the staff name’s to confidentiality I will use a pseudonym to protect the patient and nursing home staff information (NMC, 2008).
My pseudonym is Mr TC for the patient and Mr Anthony Adams. Pseudonymisation is a process that aims to provide a confidential solution to service users that are known to Trust (SLAM, Confidential Policy, 2010). I will discuss nursing professional issues of confidentiality and record keeping from different perspectives including nursing code of conduct, local Trust and national policies, common law applied to professional practice and ethics and other literature. Nurses have legal and professional responsibilities to respect the rights of patients and to treat them equally.
Patient’s records are to be kept confidential at all times. When a nurse accesses the patient records, the nurse is not to discuss the patient’s conditions or any other confidentiality information with anyone not assigned to care for the patient. According to nursing and midwifery (NMC) code of conduct (2008) “states that nurses must respect patient’s right to confidentiality and must ensure patients are informed about how and why information is shared by those who will be providing their care”.
South London and Maudsley (SLAM) NHS Foundation Trust “states that confidential information about patients can only be used for healthcare purposes and unless exceptional circumstances are present, can only be disclosed with the informed consent of patients. Where the patient lacks capacity and unable to consent, information should only be disclosed in the patient’s best interest”. Nurses are to keep patients best interest in mind at all times, in order to avoid professional issues that could arise.
Department of Health (DoH, 2003) “states that the duty of confidentiality arises when patient discloses information to clinicians in circumstances where it is reasonable to expect that the information will be held in confidence. Confidentiality is a legal obligation that is derived from case law rather than an Act of Parliament, built up over many years and often open to different interpretation. Confidentiality is also a requirement established within professional codes of conduct and there should be specific requirements within NHS employment contracts linked to disciplinary procedures.
It is generally accepted that information provided by patients to the health professional, is provided in confidence and must be treated as such so long as it remains capable of identifying the individual it relates to. Once information is effectively anonymised it is no longer confidential”. The Data Protection Act 1998 tightened up access to disclosure to personal information by putting on the decisions of the individual nurses. SLAM (2010) “states that Data Protection Act 1998 is the legislation that provides a framework that governs the processing of information that identifies living individual-personal data in Data Protection terms.
Processing includes holding, obtaining, recording, using and disclosing of information and the Act applies to all forms of media, including paper and images. It applies to confidential patient information but is far wider in its scope as it covers all staff records”. DoH (2003) “states that Data Protection Act 1998 (DPA98) is a framework that governs the processing of information that identifies living individual-personal data in Data Protection terms.
Processing includes holding, obtaining, recording using and disclosing of information and the Act applies to all forms of media, including paper, and images. The Act applies to confidential patient information but is far wider in its scope, e. g. it covers personnel records”. SLAM (2010) “states that common law is built up from case law where practice has been established by individual judgements. The key principle is that information provided in confidence should not be used or disclosed further, except as originally understood by the confider, or with their subsequent permission.
Whilst judgements and other relevant legislation have established that the duty of confidentiality can be overridden “in the public interest”, these have centred on case-by-case consideration of exceptional circumstances”. DoH (2003) “states that common law of confidentiality is not codified in an Act of Parliament but built up from case law where practice has been established by individual judgements. The key principle is that information confided should not be used or disclosed further, except as originally understood by the confider, or with their subsequent permission.
Whilst judgement have established that confidentiality can be breached “in the public interest, these have centred on case-by-case consideration of exceptional circumstances. Confidentiality can also be overridden or set aside by legislation”. SLAM (2010) “states that nurses have a duty to report any breaches of confidentiality involving transfer as soon as these occur as this is the only way that the Trust can continue to safeguard the integrity of the information entrusted by patients”. The Trust follows the Department of Health Checklist for Reporting, Managing and Investigating Information Governance Serious Untoward Incidents.
NMC (2005) “states that quality of record keeping is a reflection of the standard of professional practice, it is a mark of the skilled and safe practitioner practice, whilst careless or incomplete record keeping often highlights wider problems with the individual’s practice”. Griffith & Tengnah (2008) “states that records are the key communication tool between nurses, it is essential that record entries can be read with clarity of the entry”. NMC (2008) “states that as a nurse you must complete records as soon as possible after an event as occurred.
Griffith & Tengnah (2008) “states that record entries need to be written at the time of, or as soon as possible after the events to which they relate”. You must ensure all records are kept securely and keep clear and accurate records of the discussions you have, the assessments you make, the treatment and medicines you give and how effective these have been”. Wood (2003)” states that nurses must ensure that the health care record for patient is an accurate account of treatment, care planning and delivery of care.
It should be written with the involvement of the patient wherever practicable and completed as soon as possible after an event has occurred. Nurses should provide clear evidence of the care planned, the decisions made, the care delivered and the information shared”. DoH (2006) “states that record keeping system, whether paper or electronic, should include a documented set of rules from referencing, titling, indexing and if appropriate, the protective marking of records and this should be easily understood to enable the efficient retrieval of information when it is needed and to maintain security and confidentiality”.
The Data Protection Act 1998 defines a health record widely. The discovery process of a case allows any material document to be used as evidence, any document that records any aspect of the care of a patient can be required as evidence before a court of law or before any of the regulatory bodies. The rules of the court demand that all documents are produced (Rules of the Supreme Court Order 24). It is important therefore that nurses do not view record keeping as a mechanistic process, in litigation the outcome is not based on truth but proof. If it is not in the notes it can be difficult to prove it happened (Griffith & Tengnah, 2008″).
To reflect my interaction with Anthony I will use Gibbs (1998) reflective cycle. Academic nurses (2010) “as stated by Gibbs that reflective cycle is straight forward and encourages a clear description of the situation, analysis of feelings, evaluation of the experience, analysis to make sense of the experience to examine what should be done if the situation arises again”. Department of health (DoH) (2003) “states that staff should check with callers in person or by making telephone call to confirm who they are, and to seek official identification or check identity”.
When I received Anthony at the main ward door, after greeting and introducing myself I asked him of the person he intended to visit, he then stated that he was sent to collect some documents that belong to a discharged patient named TC. When I asked him of his identification badge from his work he stated that he did not have one. Due to patients confidentiality purpose I did not let him in to the ward. When Anthony said that he did not have an identity I did not send him away or withdraw from attending to him.
I respected Anthony as an individual when he said that he did not have an identification badge. I did not degrade or shame him as it was his self-determination co come down to the ward without a proof of identity. I did not jump to conclusion to blame him for his actions that he was supposed to bring an identity with him (Knapp, 2007). Before letting Anthony in to the ward in order to minimise risk of harm through impersonation and being an open and medium secure ward risk is unpredictable, I told him to wait outside so that I can confirm with a qualified staff as I do not know the named patient.
Trust’s policy on secure environment (2008) “states that successful and effective security risk management processes must identify risks posed to services and personnel”. On getting to the qualified staff he stated that TC was discharged from the ward to a nursing home about a month ago. My supervisor then left what he was doing immediately and we both came together to attend to Anthony. As I am accountable for my own actions if Anthony is allowed to the ward without verifying from a qualified nursing staff to know his motive, so I used my initiative before letting him in.
Griffith and The discussions made with Anthony regarding TC were not at the ward main door in order to respect TC’s confidentiality. Royal College of Psychiatrists (2010) “states that healthcare professionals working in mental health services are bound by law and professional codes of conduct to a duty of confidentiality to their patients” As I am accountable for my own actions if Anthony is allowed to the ward without verifying from a qualified staff to know his motive, so I used my initiative before letting him in.
Griffith and Tengnah (2008) “states that as a nurse you will be legally and professionally accountable for your actions, whether you are following instruction of another nurse or using your own initiative”. When Anthony gave me his work place telephone number to enquire about him from the nursing home, I then rang the telephone number given; fortunately it was the nursing home manager that picked up the phone. As I asked to confirm if she has sent anybody on behalf of TC to collect some documents, she immediately mentioned Anthony’s name.
After Anthony has given me TC’s name and full address I quickly cross checked on electronic patient journey survey (ePJS) to make sure that the address given by Anthony corresponds with TC’s name and current address on the system. Caldicott principles “states that it is crucial that nurses must understand the reasons for processing personal identifiable information (SLAM, Confidential Policy)”. While I was checking the ePJS to confirm TC’s information I expect to find the records of property check list but there was no record of it.
So I decided to check his clinical folder where a list of the documents taken during admission was found. To evaluate what was good about the incident. I was able to communicate effectively with Anthony and the home manager by making an inquiry through the use of telephone before making a decision whether or not to release to documents to him. Although, the documents did not contain clinical information but the information of the documents were identifiable. As a result the documents can be used fraudulently by anybody.
O’Carroll & Park (2007) “states that communication is a key part of mental health nurse’s work, and it is important to be able to communicate verbally or face to face or by telephone, or written in form of letters, reports, care plans or records”. To evaluate what was not so good about the incident. The Home Manager could have given TC a choice of contacting the ward to request for his documents and to be able to make us aware that a member of staff of the nursing home will be coming down to collect the documents on his behalf.
Kohner (1996) “states that patients should be care for as individuals, respecting each patient as an autonomous person which involves giving patients choice, information and power”. As a nursing student on the ward I was not aware that TC was a discharged patient from the ward. If the home manager has called the ward that Anthony would be coming at a specific day or time I could be aware of Anthony’s coming either through handover or the ward diary which could have made me not to be embarrassed when I met him at the ward main door.
Another thing that was not so good was the entries of TC’s documents that were not made on the ePJS. Example is Victoria Climbie’s Inquiry which showed that record entries of with uneven spaces between them, leading the barrister to the inquiry to suggest that the note about the phone call to social services was added after the girl’s murder in an effort to explain away the fact that she had done nothing with her referral (Griffith& Tengnah, 2008).