Record-keeping in care settings follows strict laws and guidelines to protect personal and health information. The main legislative frameworks and acts include:
Data Protection Act 2018 (DPA 2018)
The Data Protection Act 2018 adapts the General Data Protection Regulation (GDPR) for the UK. It dictates how personal data should be processed and stored, especially in health and social care.
Key rules are:
- Lawfulness, Fairness, and Transparency: Process data legally, fairly, and openly.
- Purpose Limitation: Collect data for clear, specific reasons.
- Data Minimisation: Only gather what is needed.
- Accuracy: Ensure data is correct and updated as necessary.
- Storage Limitation: Keep identifiable data only as long as needed.
- Integrity and Confidentiality: Protect data from unauthorised access or loss.
These principles ensure that sensitive health records are managed securely.
The Health and Social Care Act 2008
The Health and Social Care Act 2008 established a regulatory system run by the Care Quality Commission (CQC). This body oversees care quality in services across England.
The act requires care providers to keep detailed and accurate patient records.
This act states:
- The need to maintain proper records for safe and effective care.
- The requirement to keep these records secure, protecting individuals’ confidentiality.
- The duty to ensure records are accurate, complete, and up-to-date.
The Care Act 2014
The Care Act 2014 focuses on adult social care, including record keeping. It details how care records should be managed to meet individuals’ needs.
Key aspects include:
- Promoting transparency and accountability in care.
- Ensuring proper documentation and regular reviews of care plans.
- Protecting individuals’ data and using it appropriately for care planning.
Professional Regulatory Bodies
Bodies like the General Medical Council (GMC) for doctors and the Nursing and Midwifery Council (NMC) for nurses provide detailed guidance on record keeping as part of their practice standards.
Guidelines and Best Practices
Care providers should follow guidelines from bodies like the National Institute for Health and Care Excellence (NICE). NICE offers comprehensive advice on maintaining accurate patient records to support continuity and quality of care.
Summary
The Data Protection Act 2018, the Health and Social Care Act 2008, and the Care Act 2014 form the legal framework for record keeping in UK health and social care. Compliance ensures that records are managed accurately, securely, and ethically.