3.4 Maintain healthcare records in line with legislation and organisational requirements

Course: NVQ Level 5 Diploma In Leadership & Management for Adult Care

Unit 5: Person-centred practice for positive outcomes

LO3: Lead practice in appropriate health and care methods to achieve person-centred outcomes

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3.4 Maintain healthcare records in line with legislation and organisational requirements

It is important to maintain healthcare records in line with legislation and organizational requirements. This helps to ensure that all data is safe and secure and that it can be accessed as needed.

Organizational requirements may vary, but often include standards for file naming, storage location, and retention. Records must be kept for a certain period of time (which may be specified by law), after which they can be destroyed or deleted.

It is important to consult with your organization’s records management department to ensure that you are adhering to all requirements. Failing to do so can result in fines or other penalties.

The Data Protection Act 2018 will come into force on the 25th of May 2018. The General Data Protection Regulation (GDPR) is a new piece of legislation introduced by the European Parliament and Council, which includes regulations that apply to all organizations processing personal data of people located in the European Union (EU).

The act brings together existing data protection law for the first time, providing a single set of rules that organizations can apply to ensure compliance. In addition, it adds new requirements in some areas and clarifies requirements across all processing sectors. It also simplifies the regime, modernizing and harmonizing data protection law across Europe.

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The GDPR strengthens the rights individuals have over their personal data: giving them more control and strengthening the requirements on organizations to report personal data security breaches

It is the responsibility of all health care professionals to ensure their compliance with the GDPR. This means they must know what processing activities are taking place under their name, and how this takes place.

The act requires that you know who is able to access patient records (both inside and outside the healthcare institution), and what purposes they have for this access. You must also understand how security is maintained over the records, as well as locating them in a secure place where staff can be trained to handle them appropriately.

Generally, you must ensure that all members of your team are aware of the need to protect patient data whenever it is being used or accessed. This involves keeping it safe, by ensuring that you store all forms of patient records in a secure place without access to the public.

You should also know how long your records must be kept for, and ensure that they are disposed of or deleted when appropriate. You are responsible for this within your organization but may need to take advice from your records management company.

In order to ensure that data protection is not compromised, a Public Authority must appoint an individual as their Data Protection Officer (DPO). The DPO will act as the authority on all things related to this role and provide advice about how best to protect yourself when it comes time for you to handle any personalized information belonging to those within your organization.

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