Competency: 5

Details

Create and use patient-related data, applying data and information security best practice in a clinical context, and advise and support peers and colleagues about data and information security best practice related to patient information.

Considerations

• How routine direct online access to their records provides patients with evidence-based information to help them make decisions about care, including self-care.
• Sources of information about patient and public views and expectations for healthcare and related services.
• The importance of data transparency, on the assumption that all data is available to the patient.
• The benefits and risks, for both patients and professionals, of patient record access and sharing; how to maximise the benefits, how the consultation is affected by patient record access and how the system is affected by record access.
• Decision aids.
• Transactional services for patients, e.g. appointment booking, requesting repeat prescriptions, the ability of patients to add to their record.
• Principles of acceptable, effective communications and information exchange with patients and carers and how this can be achieved in clinical practice.
• Implications of patient-held and patient-accessible clinical information for interprofessional clinical practice and multidisciplinary care.
• How coding impacts on the production of information that patients are able to access.
• Nature and importance of shared meaning for interprofessional communications.
• Purpose, basic structures, use and storage of patient health records, including paper-based and electronic patient records, and patient-held records.
• Differences and importance of both structured, coded records and free text.
• Basis, application and limitations of the different clinical coding systems in use, including terminologies, classifications and related vocabularies.
• Use of clinical terms in recording clinical information in the patient record, and how that can facilitate reporting and analysis.
• The importance of high-quality coded clinical data for the quality of clinical practice, the safety of patients and the communication of clinical information.
• Data, information and knowledge – similarities and differences with regard to security and confidentiality.
• Security and confidentiality risks and issues associated with patient-based data and information in paper and electronic forms in primary and acute settings.
• Sharing data and information across sectors, i.e. health, social care and public health – risks, issues and challenges.
• Patient and the public perspectives on personal information security, confidentiality and record sharing, including consent.
• Records access – overview of the strategies, politics and practice; rights, roles and responsibilities.
• How routine online patient record access influences the behaviour and attitudes of patients and professionals.
• Record-keeping standards.
• The qualities of good data and information and secondary uses of information.

Relevant learning outcomes