Tuesday, July 05, 2005
CU5
KNOWLEDGE EVIDENCE QUESTIONS
UNIT CU5 - RECEIVE, TRANSMIT, STORE AND RETRIEVE INFORMATION
1List the regulations/hospital policies that affect the gaining of information?
the Data Protection Act
The Freedom Information Act
2Briefly describe your responsibility in relation to the above regulations/hospital policies.
Individuals have the right to confidentiality of their care and medical history so my role is to reduce their risk of information being transferred to the wrong person and facilitating the relevant information being passed to the correct person.
3Through what sources can you obtain information about patient care?
The client themselves
The clients' friends
the clients' relatives (it must be noted that these are three sources may be subject to bias and may not be totally valid sources. Also, individuals can make mistakes, so care must be made when using these sources)
The client care plan
The client's medical notes
4How do you ensure that the information gained is relevant and correct?
objective information he's the most desired as it is without bias. However, 100 per cent objective information is really impossible to obtain because, at some level, subjective feelings come into play. It is therefore important to eliminate subjective feelings as much as possible when trying to gain information. If, for example, a client is confused, a relative or friend maybe a more suitable source of information than the client themselves.
it would be hoped that if a source is a another professional, that them this information would be more valid than a more subjective one. However, professionals, themselves been human, are subject to bias themselves.
5Briefly describe the different purposes for which information may be required in your work area and the degree of detail necessary for each purpose.
Handover
Handover information needs to be succinct and relevant to the client. It needs to be free from bias and, because it is verbalised, a suitable venue needs to be found for its delivery. Care needs to be taken when giving goal handover in front of the patient because do so she/he the main not want to here that they have cancer or they may not wish everyone in the bay to here when they last had their bowels open.
Clare plans
Again, information is to be six into relevant. Been succinct still need to be maintained, however, there is more room for morning depth information to berecorded . as clients have access to their care plans, care must be taken when recording in them and his reach its to be taken into consideration when recording anything in a care plan. Care plans need to be kept in the appropriate place, in an hour case, in the trolley pertaining to the baby in which the client is situated, when the care plan is not being used. Clients have access to their own care plan. Because an individual is a relative of a client, this does not guarantee that they have access by right to the information recorded in the care plan.
Medical notes
These are far more in depth tomes that clients do not have direct access to. A client does have access to their medical notes under certain circumstances. These arc, when the client requests in writing to see only a certain portion of the notes over which are the relevant consultant has veto. Once these have been accessed, they must be returned to the relevant notes trolley.
6How are patients’ records obtained on admission and transfer?
On admission
Clients are usually accompanied by a letter from their general practitioner or, if they have been admitted via ambulance, documentation from that service. From this information, a temporary medical notes are raised. If a relevant doctor sees fit, clients' medical modes I'll are located.
When a climb need to be transferred, then notes, if they are in the same location as the client, do with the client to the new location. It is essential that any confidential notes, such as medical notes, remain confidential. Also, as the client has not requested to see the medical notes at that point, the client themselves must not read the medical merits or any other confidential information. The database of the location of all medical notes is then updated so, at any point, though it can be traced if necessary.
7Where are the client’s medical and nursing notes stored in your work area?
In the relevant rate trolley pertaining to the Bay in which they are located.
8Who has the right to access these notes?
see Question 5
Also further to this, only relevant members of the multi-disciplinary team should have access to clients of nodes are who they are directly looking after. If as a professional is not looking after her a a patient, then they should not be accessing their notes.
9How should the notes be transferred between wards, departments and hospitals?
they should be transferred in specifically designed nodes bags ideally. The client to whom they pertain should not have access to them.
10Where are they stored when the patient has been discharged home?
Usually, notes her are stored at the Medical Records store.
11What is your responsibility with regards to patients’ notes?
Information the in them should be correct and accurate
Information should be legible and be a bias free
They should be stored in a manner appropriate to the type of notes
Actions to should be taken as to reduce risks of breaches in confidentiality
12A patient asks you if they can see their notes or a parent asks to see their childs notes. What should be your reply?
I would say that this shy and not in a position to allow any individual to look at the Medical notes belonging to others and would refer them to the registered practitioner.
13To whom do the notes belong?
medical notes belong to the health authority
Care plans belong to the client they pertain to
14What is the procedure for the notes in the event of a fire?
the although medical notes are very important, human life is far more important so it is far more important stat human life is preserved over that of medical notes.
15A relative on the ‘phone asks you what is wrong with their mother/daughter. How would you deal with this call?
as a health care support worker, a I am responsible for my actions. I am not accountable for them in the way in which a qualified what nurse is. Therefore, it is not my responsibility to discuss client diagnosis with a are either the client or their significant others. In this instance it, therefore, I would I get suggest that I'd take a telephone to the client in question, if they were unable and capable of talking on the telephone, or I would pass them over to be qualified nurse in question.
16What do you need to consider when speaking to people on the telephone?
Who are you talking to?
Who is listening where you areand where the individual this was on the phone?
What are they asking?
Are they who they say they are?
Do I need to pass a the call onto a more relevant person or am I able to answer this call within my role?
17When writing down a message, how do you ensure relevancy, accuracy and currency of information?
Be brief
Only record that which is necessary
Check for accuracy with others such as client themselves, significant others, or other healthcare professionals
18Why is it important to take messages accurately?
to facilitate beneficence
to reduce maleficence
19What actions need to be taken after obtaining this information?
Only the person for whom the information is intended accesses it
Others who do not need to access the information should be denied from doing so
The information should be placed/ recorded in the relevant place
20What do you need to consider when passing information to colleagues/relatives?
do these individuals specifically need to know?
Is it in their best interest?
Is it in the best interest of the client ?
As the client given consent?
Is it within the role of the information to giver to impart this information ?
21List the different types of charts used in your work area.
Observation charts
Fluid charts
Bowel charts
Weight charts
Food charts
Peak flow charts
Insulin sliding scale charts
Standard blood glucose level charts
22Who is responsible for maintaining these charts?
The registered practitioner that is accountable for the filling in of these charts. However, if a health care support worker has been designated to fill in any specific chart that is within their role then it is the responsibility of that said worker
23Why are these charts necessary?
It they show what has happened to a client
They provide a benchmark on admission against which any change maybe measured
The show if any changes in climate condition have occurred or are likely to occur
24Briefly describe the kind of problems that can arise during the maintenance and storage of these charts and the action you should take.
There is not enough room to fit in at a certain piece of information within the chart . Get a new chart
There is a chart without a name on in a patient's nodes. All paperwork should have Client name and number on it before it is written on.
UNIT CU5 - RECEIVE, TRANSMIT, STORE AND RETRIEVE INFORMATION
1List the regulations/hospital policies that affect the gaining of information?
the Data Protection Act
The Freedom Information Act
2Briefly describe your responsibility in relation to the above regulations/hospital policies.
Individuals have the right to confidentiality of their care and medical history so my role is to reduce their risk of information being transferred to the wrong person and facilitating the relevant information being passed to the correct person.
3Through what sources can you obtain information about patient care?
The client themselves
The clients' friends
the clients' relatives (it must be noted that these are three sources may be subject to bias and may not be totally valid sources. Also, individuals can make mistakes, so care must be made when using these sources)
The client care plan
The client's medical notes
4How do you ensure that the information gained is relevant and correct?
objective information he's the most desired as it is without bias. However, 100 per cent objective information is really impossible to obtain because, at some level, subjective feelings come into play. It is therefore important to eliminate subjective feelings as much as possible when trying to gain information. If, for example, a client is confused, a relative or friend maybe a more suitable source of information than the client themselves.
it would be hoped that if a source is a another professional, that them this information would be more valid than a more subjective one. However, professionals, themselves been human, are subject to bias themselves.
5Briefly describe the different purposes for which information may be required in your work area and the degree of detail necessary for each purpose.
Handover
Handover information needs to be succinct and relevant to the client. It needs to be free from bias and, because it is verbalised, a suitable venue needs to be found for its delivery. Care needs to be taken when giving goal handover in front of the patient because do so she/he the main not want to here that they have cancer or they may not wish everyone in the bay to here when they last had their bowels open.
Clare plans
Again, information is to be six into relevant. Been succinct still need to be maintained, however, there is more room for morning depth information to berecorded . as clients have access to their care plans, care must be taken when recording in them and his reach its to be taken into consideration when recording anything in a care plan. Care plans need to be kept in the appropriate place, in an hour case, in the trolley pertaining to the baby in which the client is situated, when the care plan is not being used. Clients have access to their own care plan. Because an individual is a relative of a client, this does not guarantee that they have access by right to the information recorded in the care plan.
Medical notes
These are far more in depth tomes that clients do not have direct access to. A client does have access to their medical notes under certain circumstances. These arc, when the client requests in writing to see only a certain portion of the notes over which are the relevant consultant has veto. Once these have been accessed, they must be returned to the relevant notes trolley.
6How are patients’ records obtained on admission and transfer?
On admission
Clients are usually accompanied by a letter from their general practitioner or, if they have been admitted via ambulance, documentation from that service. From this information, a temporary medical notes are raised. If a relevant doctor sees fit, clients' medical modes I'll are located.
When a climb need to be transferred, then notes, if they are in the same location as the client, do with the client to the new location. It is essential that any confidential notes, such as medical notes, remain confidential. Also, as the client has not requested to see the medical notes at that point, the client themselves must not read the medical merits or any other confidential information. The database of the location of all medical notes is then updated so, at any point, though it can be traced if necessary.
7Where are the client’s medical and nursing notes stored in your work area?
In the relevant rate trolley pertaining to the Bay in which they are located.
8Who has the right to access these notes?
see Question 5
Also further to this, only relevant members of the multi-disciplinary team should have access to clients of nodes are who they are directly looking after. If as a professional is not looking after her a a patient, then they should not be accessing their notes.
9How should the notes be transferred between wards, departments and hospitals?
they should be transferred in specifically designed nodes bags ideally. The client to whom they pertain should not have access to them.
10Where are they stored when the patient has been discharged home?
Usually, notes her are stored at the Medical Records store.
11What is your responsibility with regards to patients’ notes?
Information the in them should be correct and accurate
Information should be legible and be a bias free
They should be stored in a manner appropriate to the type of notes
Actions to should be taken as to reduce risks of breaches in confidentiality
12A patient asks you if they can see their notes or a parent asks to see their childs notes. What should be your reply?
I would say that this shy and not in a position to allow any individual to look at the Medical notes belonging to others and would refer them to the registered practitioner.
13To whom do the notes belong?
medical notes belong to the health authority
Care plans belong to the client they pertain to
14What is the procedure for the notes in the event of a fire?
the although medical notes are very important, human life is far more important so it is far more important stat human life is preserved over that of medical notes.
15A relative on the ‘phone asks you what is wrong with their mother/daughter. How would you deal with this call?
as a health care support worker, a I am responsible for my actions. I am not accountable for them in the way in which a qualified what nurse is. Therefore, it is not my responsibility to discuss client diagnosis with a are either the client or their significant others. In this instance it, therefore, I would I get suggest that I'd take a telephone to the client in question, if they were unable and capable of talking on the telephone, or I would pass them over to be qualified nurse in question.
16What do you need to consider when speaking to people on the telephone?
Who are you talking to?
Who is listening where you areand where the individual this was on the phone?
What are they asking?
Are they who they say they are?
Do I need to pass a the call onto a more relevant person or am I able to answer this call within my role?
17When writing down a message, how do you ensure relevancy, accuracy and currency of information?
Be brief
Only record that which is necessary
Check for accuracy with others such as client themselves, significant others, or other healthcare professionals
18Why is it important to take messages accurately?
to facilitate beneficence
to reduce maleficence
19What actions need to be taken after obtaining this information?
Only the person for whom the information is intended accesses it
Others who do not need to access the information should be denied from doing so
The information should be placed/ recorded in the relevant place
20What do you need to consider when passing information to colleagues/relatives?
do these individuals specifically need to know?
Is it in their best interest?
Is it in the best interest of the client ?
As the client given consent?
Is it within the role of the information to giver to impart this information ?
21List the different types of charts used in your work area.
Observation charts
Fluid charts
Bowel charts
Weight charts
Food charts
Peak flow charts
Insulin sliding scale charts
Standard blood glucose level charts
22Who is responsible for maintaining these charts?
The registered practitioner that is accountable for the filling in of these charts. However, if a health care support worker has been designated to fill in any specific chart that is within their role then it is the responsibility of that said worker
23Why are these charts necessary?
It they show what has happened to a client
They provide a benchmark on admission against which any change maybe measured
The show if any changes in climate condition have occurred or are likely to occur
24Briefly describe the kind of problems that can arise during the maintenance and storage of these charts and the action you should take.
There is not enough room to fit in at a certain piece of information within the chart . Get a new chart
There is a chart without a name on in a patient's nodes. All paperwork should have Client name and number on it before it is written on.
# posted by alanpjack @ 7:55 AM 
