When maintaining records information should be written to adhere to the settings standards in order to be effective, accurate and safe which may include: •The presentation is clear and legible (if hand writing) and that the information is written in a way that others can understand, this makes it easy for other people to read and comprehend, and data is passed in a clear and logical way. •Records must be made as soon as possible after the events to which they relate this provides current information of the service user.
•Records must be an accurate and evidence based record of what took place, ensuring that it is documented the difference between your opinion, the facts, the evaluation and the plans, so it is easy to follow the details and be clear of the event. •Record the time and date that the event, making sure your name, signature and designation is clearly documented in the content of the entry, so that there is no doubt exactly when the event being documented occurred and to identify who has documented the information.
•Only relevant information is to be documented, ensuring that information is passed on a need to know basis. Storage of information It is important that we keep personal information stored securely, ensuring that confidential information is not unlawfully or inappropriately assessed. This means that we must not leave information hanging around where it may be seen by others and we must use used the lockable cabinets provided by your setting to store information safely; these cabinets should be kept behind a lockable door which should be kept locked whist not in use.
We should ensure that our computers have secure passwords which are changed regularly and that and that any IT portable storage and emails are encrypted. Make sure that passwords are not shared and that you log off before letting someone else use the computer Keeping information safe whist in use Ensuring information is handled safely when in use of documentation is in use is very important as you may be unaware of who is looking at private information. It is important that we write our notes up in your office or a private place, not leaving documents unattended.
Information regarding personal information should be discussed on a need to know basis ensuring that other individuals are not overhearing conversations, and that information is only discussed in a professional setting, not when socialising. Special features of storage systems in order to help security. Regardless of what systems of information is in place in your setting you are required by the law and your settings policies and procedures to follow confidentiality guidelines and to respect people’s right to privacy.
Upon signing your contract and terms of employment you have agreed to keep information confidential. A manual information security storage system is usually kept in a secure environment with controlled access there are normally locked cabinets or similar locked storage area with access to keys limited to authorised people/staff, the cabinets are usually has a lock and is generally made from sturdy construction materials, such as metal.
An electronic information security storage system is usually in the form of a computer it is accessed by individual password to each member of staff, the screen can be locked (which is password protected) when you are a way from it, information can be encrypted and anti-malware software should be in place to protect the computer from untoward viruses, systems can be backed up and non-confidential information can be stored on a centralised shared drive. Programmes which hold personal information usually have restricted users, ensuring only information according to your job role is provided.