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3.3b Information Sharing Case Study (Mrs. Horton)

Old lady in Hospital Bed (Mrs. Horton)

Mrs Horton is 81 years old and has lived alone in her two bedroomed house for many years. She is frail and has difficulty moving around due to chronic obstructive pulmonary disease which leaves her breathless after only a little exertion. She has home care visits, three times a day to support her with getting up, getting lunch, and preparing her evening meal whilst also helping her to undress for bed. She has a stair lift to help her upstairs where the only available toilet is.

She has a son who lives locally but works away most of the time and she has a daughter who lives 200 miles away and is unable to drive. A friend collects her to take her to church every week and another friend takes her to the hairdressers every week. Currently she also has a visit from the diabetic nurse every week.

Two weeks ago, she had a fall and was admitted to hospital. Following observation and some treatment, she is now ready to return home, with new medication.

Use this template to consider information that should be shared to support Mrs Horton.

Consider what information needed to be shared at the point of admission.
InformationBy whomWith whomWhen
Name, address, details of accidentParamedicsHospital admissionsAdmission
Medical history and current medicationPrimary Care (GP, Diabetes Nurse)Hospital admissionsAdmission
Mrs. Horton’s condition (if consent given)Hospital NursesMrs Horton’s Family and Friends and Support StaffAdmission
Consider what information needed to be shared before Mrs. Horton returns home.
InformationBy whomWith whomWhen
New Medication and ConditionHospitalMrs Horton’s Family/Friends/Support StaffDischarge
Medication, treatment and ConditionHospitalPrimary Care (GP, Diabetes Nurse)Discharge
What steps do you need to take in order to share this information?
Where possible, consent should be obtained from Mrs. Horton before any information sharing goes ahead. Where this is not possible, a judgment call will need to be made and information should only be shared on a need to know basis
Consider the possible consequences of not sharing information in this situation
Family, friends and support staff would worry about Mrs. Horton when they visited her home and found her not there. Medical professionals would not have full access to her medical history and current medication so may give her inaccurate advice (e.g. putting her on medication which is incompatible with medication she is already taking). Medical staff would not know her name or how to address her.

3.3a Find out what consent model your organisation employs for personal data of people who access care and support

describe a situation where this has been put into practice

When contracting us to provide their care and support, clients are informed that staff may share their information with other professionals and/or their families as long as it is in their best interests and on a need-to-know basis. Clients can choose to sign to agree to this or not.

A client I work with had agreed to this, which meant that I was able to share details of his support plan with his social worker so that she could complete his assessment.

Describe how the situation would have been handled differently if an alternative consent model had been adopted

By having a cover-all consent model as long as it is best interests, the social worker was able to complete her assessment quickly without having to ask the client for consent multiple times.

What impact would this have had on the individual?

If the client were to be repeatedly asked for consent, this may have resulted in them becoming bored and lack motivation to complete the assessment. It could also result in them becoming upset or angry.

Conversely, if the client had not been asked for consent at all, as well as breaking the law this may have resulted in them feeling less valued, lower self-esteem and lower confidence.

compare the ethical and moral dilemmas involved in both models

Both opt-in and opt-out consent models allow the individual to make an informed choice.

3.2b Use this template to consider the effectiveness of the systems you have identified above.

What is/are the main reasons for having systems?

To ensure adherence to legislation and good practice, that confidential information is secure and correct records are kept.

Who is the information and data for?

The information is for staff, clients and the business.

Who owns the data and information?

The company owns the data

how do the systems in place meet legal and ethical requirements?

Confidential and personal information is secured and only accessible on a need-to-know basis.

reflect on the links to respect and privacy issues for the data and information in your systems

The online system only allows access on a need-to-know basis. Similarly, paper records are locked away and secured to ensure that only the relevant individuals can obtain access to them. This is covered by GDRP.

3.2a Reflect on your own information management system. For each piece of information stored complete the following grid.

 

InformationWho completes/stores?Who monitors?How is it stored/secured?Who has access?
Support/care plansManagers and seniorsManagers/seniorsOnline systemClient, support staff
Personal information of people who access care and supportManagers and seniorsManagers and seniorsOnline systemClient and support staff
Personal staff filesHRHRLocked filing cabinet in locked officeHR

Staff can ask to access their own files

Supervision/appraisal documentsManagers, seniors and HRManagers and seniorsLocked filing cabinet in locked officeHR, managers and seniors
Statutory information, advice, guidanceRegistered manager, managersRegistered managers, managersOnline systemAll staff
Other

3.1b Reporting and Recording Systems

Explain the difference between subjective and objective recording

Objective recording only contains the facts, whereas subjective recording also contains the individual’s own personal thoughts, feelings and views.

From your experience, identify three consequences of inaccurate or incomplete records
  1. An appointment is missed
  2. Time is spent doing something that has already been completed by someone else
  3. Medication overdose (given twice as first administration was not recorded)
Consider why and how you might share records with people who access care and support, carers and relatives

Personal information about a client should only be shared with their consent unless not doing so would result in harm or injury to themselves or others or result in the law being broken.

Information should then only be shared in a private setting and on a need-to-know basis and should also be in the client’s best interests.

What difference might this make to the format and storage of any records?

Records should be kept and archived until no longer needed.

Provide specific examples of how you might use accurate records to support positive outcomes for people who access care and support

Showing records of a clients meals and snacks to their dietitian so that they can offer the best health advice for the individual.

Informing a pharmacist of the conditions and current medications of a client  before supporting them to buy over-the-counter medication.

 

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