When accessing the individual’s records make sure you follow all the relevant policies, procedures and guidelines.
These include: The Data protection act 1998
Our organizations policy on record keeping
Our organizations policy on access to records
Our organizations policy on confidentiality
Also ensure that the permission of the service user is obtained either verbally or written, whichever is the most relevant. It is always good to ask the manager of the home or the relatives of the service user where appropriate if the service user is unable to give permission themselves.
Finally also ensure that the service users care plan, MARR sheet and any other personal documents are not left where non relevant staff members or other service users can access them. They are stored safely in the manager’s office according to our policies and procedures.