Record keeping is an integral part of Nursing, Midwifery and Health Care practice and is essential to provision of safe and effective care (1). In addition to documenting synchronous patient care, good record keeping is essential for clinical audit, patient safety and patient decison making, promoting contiunuity of care across inter-professional and inter-agency boundaries, showing how patient decisions were made, and addressing complaints and subsequent legal processes (2).Provides not only have to ensure that what is written by their staff is factual and correct but is suitable for different audiences namely residents, realtives, the employer, the regulatory bodies and in some cases the court (3).
Record keeping must be confidential. It means keeping information safe and private. Confidentiality is an important value within the healthcare setting for clients, their families and employees. Personal and private information such as health diagnosis, feelings, emotions and financial status must be resticted to people who have an accpeted need to know. Nurses, doctors, health care workers, managment have rights to confidential information about a patient (4).
In 1997 a report about confidentiality was produced by a committee chaired by Dame Fiona Caldicott. Their brief had been to review the transfer of person identifying information in the health service. The result was a set of standards that became know as a Caldicott Principiles.
Within Devon Social Care Srevice- ACS and CYPS, staff may, according to their role, be required to have access to different types of information or ‘’data’’. This information is often about people and may be in many forms ( such as written, on computer or verbal).
Caldicott is related to and is supported by:
1. Human Rights Avt 1998
2. The Data Protection Act 1998
3. The common law duty of confidence.
The Condicott Principiles for handling Person Identifiable Information:
1. Justify the purpose for needing information...