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Healthcare Records Management In The HSE
- 1. Health Service Executive Healthcare Records Management Programme Wednesday 16 th November 2011 Irish Computer Society Data Protection Workshop
- 28. Thank you
Notas do Editor
- Gay Murphy I’ve worked with the HSE for over 30 years always in the acute hospital setting HCR Project Manager for the hospital group south east Leading out on the HCRM Programme on behalf of the Quality & Patient Safety Directorate with the support of a National Advisory Group Liam Quirke from HSE West is our advisor when it comes to DP and FOI I want to clarify when I refer to records today it’s healthcare records and not HR or Finance or any other type of records
- Today I will: define the context and set out the aims of the HCRM Programme tell you what we’ve done look at the challenges set out what you should be doing to ensure that you’re managing your records in accordance with the Data Protections Acts of 1988 and 2003
- The drivers of the programme are PATIENT SAFETY, litigation, making sure we comply with current legislation and getting our house in order in preparation for electronic patient records but today we’re going to focus on Legislation and in particular the DATA PROTECTION Acts of 1988 and 2003
- We must obtain and process the data fairly The data must be collected for a specified purpose We must only disclose the data where it is compatible with the purpose When we obtain data we must keep it safe and secure We should have procedures in place to ensure that the data is accurate, complete and up to date The personal data we hold should be relevant and not excessive We should retain the data for only as long as is necessary We must comply with an access request if a person makes an application for their personal data
- One of the key initiatives of the programme was to set Standards and develop Recommended Practices to support people in achieving the standards As part of that piece of work a national healthcare record was developed and has been implemented across the acute hospitals in the country I’m not sure if some of you here today are HSE staff working out in the community, but just to clarify the work so far has been focused on the acute services, but the programme has been extended to include all Community Services including Mental Health
- The Standards & Recommended Practices apply to healthcare records of all types which may consist of ( read from slide ) This includes the private healthcare sector where the HSE healthcare record is used
- Let me explain the importance of healthcare records and why they’re needed for us to conduct our business Healthcare records are crucial in the provision of patient care They support continuity of care and facilitate communication between all members of the multidisciplinary team. On night duty Need to know what’s my patient complaining of Is there a provisional diagnosis What happened today – did the patient have any tests or procedures Is my patient on medication? Have the meds changed or been discontinued – why? Are there alerts/allergies/risk factors that I need to be aware of? What’s the plan – does my patient need to be fasting or prepped for something tomorrow? The HCR is a legal document that provides an overview of the care and advice given to patients. HCR’s are used as evidence in litigation cases so what’s written and how it’s written is really important. No matter how much care or good advice is given, if it’s not documented then it’s assumed that it didn’t happen so records need to be available at the point of care when required Overall you can see the importance of the healthcare record
- It’s not as simple as keeping everything in a filing cabinet that can be locked at the end of the working day – 24 hour service The range and location of records to be managed varies and includes (read from slide)
- Within the acute hospital setting healthcare records need to be available for: Emergency admissions to the ED Elective admissions to the wards Day care unit for daycase procedures OPD for appointments Clinical Nurse Specialists for nurse led clinics such as diabetes care Health & Social care professionals, e.g. physiotherapy Outreach clinics, e.g. WGH hold Obstetric Outreach Clinic in Gorey As you can see the task of co-ordinating the retrieval and secure transfer of healthcare records from all areas for all services is mammoth Healthcare records are too vital to go unmanaged so good healthcare records management is crucial
- Work experience – TY students External contractors – anything from storage vendors to building contractors Volunteers – people who visit, get items from the shop, play with children in our paediatric wards That just gives you an idea of the type of challenges we face everyday in the HSE
- The ‘clear desk’ policy is very important – staff need to understand the importance of putting letters/reports out of sight and keeping them safe, i.e. not safe if left on a desk, even in a locked environment
- Your password determines your level of access so it’s crucial not to share. We must only access records on a ‘need to know’ basis
- Good practice in this area includes ( read from slide ) We must constantly strive to achieve the Standards (cannot afford to dilute)
- Managing healthcare records is vital not only in terms of patient safety but also Data Protection The Quality & Patient Safety Directorate, for its part, has developed Standards & Recommended Practices for Healthcare Records Management. The Standards were written keeping the legislation in mind and you’ll find that guidance on protecting healthcare records and maintaining confidentiality is peppered throughout.
- Personally: Laptop encrypted Remote access via secure client HSE USB Provided assurance to the National Director for QPSD by signing a declaration to ensure my personal compliance