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
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.
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