Assignment: Documenting informed consent
Assignment: Documenting informed consent
Write a 1,750- to 2,100-word paper in which you examine the legal aspects of recordkeeping and providing expert testimony. As part of your examination, address the following items:
- Analyze the ethical issues related to documenting informed consent and ethical release of treatment and assessment records.
- Which enforceable standards are relevant to the release of treatment-related materials and disclosure of information arising out of treatment?
- Provide specific examples of what each enforceable standard requires or prohibits.
- Provide a rationale for your proposed actions in your example and why they are consistent with ethical guidelines.
- Evaluate the legal issues associated with assessment, testing, and diagnosis documentation in professional psychology.
- Provide specific examples that support your evaluation.
- Provide a rationale for your proposed actions in your example and why they are consistent with legal requirements.
Include a reference slide with a minimum of 3 scholarly sources. Scholarly sources are journal articles or books. The textbook can count as one scholarly source. Websites will only be considered supplemental sources and will not be included as a part of the minimum of 3 scholarly sources.
In the first in a four-part series of articles on record keeping, Chris Payne provides guidance on the legal requirements.
Record keeping is an important, if time consuming and often irksome, activity for care service managers and their staff. They must keep many kinds of records, all of which contribute in some way, albeit not always obviously, to service users’ welfare. As it cannot be avoided, it pays to have an efficient system that meets all legal requirements. This entails treating record keeping as a total system that is planned, managed, reviewed and improved as a whole.
Service users benefit from this in a variety of ways. For example, from good recording, practice care staff and service users will be clear about what is needed, and misunderstandings and mistakes become less likely. From good equipment, maintenance recording staff and service users will know that their aids and appliances are being properly maintained, and so are less likely to break down and put their safety at risk.
Care Quality Commission requirements
The legal requirements for the keeping of records are set out in Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) 2010. The first part of the Regulation explains why records are needed — providers who do not have relevant information will jeopardise the health, well-being and safety of their service users, who then will not benefit from the services provided.
The requirements to keep certain kinds of records are broken down into two sections.
- In Regulation 20 (1a), care providers must keep accurate records and relevant documentation about the person needing the service (ie care records).
- In Regulation 20 (1b), care providers must keep corresponding records about the people employed to provide the service (ie staffing records) and the management of the service. The Regulation does not spell out what records are required for management purposes. However, it is clear that some records are always required as a result of other legislation and regulations, which apply to all business organisations (eg health and safety records). Other record keeping requirements are built into other parts of the compliance framework (eg for policies and procedures).
Having set out the requirements for the keeping of certain records, Regulation 20 turns attention to how the records must be kept.
In 20 (2), it requires any record, paper or electronic, to be kept securely, but in a place where it can be accessed promptly when needed. A record should then be kept for an “appropriate” period of time, after which it should be securely destroyed.
Taken as a whole, the Regulation lays the basis for a record keeping system that, to be legally compliant, requires care providers to pay attention to all relevant aspects, as stated in Regulation 20 and the accompanying guidance found in of the Care Quality Commission’s Guidance about Compliance: Essential Standards of Quality and Safety.