Digital Records and Ethical Challenges in Healthcare

In any organization, records and information are essential resources. Every business relies on them for survival. The capacity of an organization to make critical choices is contingent on the timely retrieval and accessibility of records. It's vital to remember that not every file is a record. A record is a document that is kept intentionally as proof of an action. A record, according to the National Archives of the United Kingdom, is a distinct piece of information created or received that has sufficient content, structure, and background to serve as proof of an action and enable intelligent decision (Mulauzi, 2019).

Records are well-known instruments for demonstrating transparency and accountability, consistency and efficacy, as well as the presence of corruption and other anomalies in a company. A company's records support a variety of operations. They allow us to plan, approve, verify, clarify, empower, track, inform, protect, suggest, mandate, regulate, advise, authenticate, terminate, comply, engage, and govern. Records include information and statistics that are used to make choices, establish strategies, and exercise control. Records assist the organization in following its policies, achieving its objectives, and meeting legal and other responsibilities (Mulauzi et al., 2013).

In the light of this, digital technology is an essential element in making sure that record keeping happiness seamlessly and records are kept private. There are many different ways, contemporarily, in which records are kept digitally. This is referred to as Electronic Documents and Records Management System or eDRMs. It is highly beneficial to incorporate eDRMs in the workplace as it ensures complete privacy of patient data, the records can be accessed much more easily than if it was physically recorded and there is less likelihood of records being misplace. A great advantage of using eDRMs is that it enables the patients to take charge of their own records. For example, the patient can ensure the accuracy of the records by filling in the frequency or nature of certain symptoms they have been facing. In this way, digital record enables the service users in health care to take their record keeping in their own hands (Queensland Government, 20 April, 2021).

Keeping records is an essential part of my own work as a health assistant and it is something that I aim to innovate in with every patient, in accordance with their needs. There are several aspects to good record keeping in health care. The medical history of the patient should be documented in good clinical notes. The health care worker is capturing all important clinical information for future reference by recording all relevant patient data. In this scenario, it is important to remember that if it didn't happen because you didn't write it down, it didn't happen. This is especially crucial in the case of a disputed medical judgement, but it also provides continuity. Because many different healthcare providers are engaged in the management of a single patient in today's medical setting, consistency in clinical notes is critical to patient care (Mathioudakis et al., 2016).

In the personal context of my own record keeping there have been some difficulties in creating and maintaining effective records of patients. The health care workers are made aware of the guidelines which they need to follow in order to ethically record and store data. According to the Data Protection Act of 2018, a health record is a record which contains any information about an individual’s health and has been prepared by or on behalf of a health practitioner in accordance with the person whose diagnosis, therapy, or treatment the data is about (Records Management Code of Practice, 2020). There was an instance where I faced some trouble regarding recording the health information of a patient. The Health and Social Care Act of 2008 dictates that health care workers must maintain records of all of the health conditions of the patient (legislation.gov.uk). I encountered a problem while attempting to do that, as on some occasions, patients were reluctant to divulge their medical information to me. This could be because of the shyness of the patient or the fact that some people think that a certain medical information is not relevant to the treatment they are seeking. In this scenario, I found it useful to explain to them that they cannot possibly know which information about their health will be relevant and hence they need to divulge all the information that will be useful for their treatment. In the future, I anticipate there may be some other problems in the future with obtaining patient information. The Caldicott principles dictate the health care workers need to comply with all the principles of the Data Protection Act of 2008 at all times (legislation.gov.uk). However, that can be compromised should the institution I am working with makes the decision to change its storage systems and upgrade, in that case the data of the patient will be transferred to other systems. In this scenario, there is a possibility that some of the patient data may be lost.

In case of my own reporting, I believe I do a good job of recording the experiences and medical and health history of the patient. I believe in gaining the trust of the patient first in order for them to give me the requisite information about their health. The format which is followed by me in recording medical information depends on what kind of medical information is being recorded and how detailed the information needs to be. There is no standard European guidance governing the structure of clinical notes. summary of state legislation on electronic health records in the member states was released in July 2014, thanks to funding from the European Union's health program. This said that all nations have employed one or more electronic health record technologies to date. It also revealed that the content requirements for these documents ranged from extensive lists to basic reference. Several professional organizations, like medical associations, nursing organizations, and healthcare trusts have developed explicit record-keeping rules, like what has to be recorded and how it needs to be recorded, and this is something worth discussing with the hospital or professional body that one is associated with. Clinical record keeping is sometimes given a low attention, despite its relevance. Illegible entries, rude comments, and missing data are widespread, and submissions by various healthcare providers are frequently inconsistent. In my personal practice, I ensure that I do not insert any form of personal comments or any messages on the document where I am taking the medical records. Because I predominantly use digital records for recording the medical data of patients, I make sure that I do not record any data which may be illegible because it was written by a human hand instead of typed on a computer.

I believe in my own practice, I would like to improve the speed of my record-keeping, as I feel I take too long to record the necessary information in the requisite forms and I need to speed up my record keeping process.

Looking for further insights on Cyber Threat Analysis? Click here.

References

Mulauzi, F., 2019. APPLICATION OF INFORMATION AND COMMUNICATION TECHNOLOGIES (ICTs) IN RECORDS MANAGEMENT.

Mulauzi, F., Wamundila, S. and Hamooya, C., 2013. The Millennium Development Goals (MDGs) in Zambia: The role of records and archives in their attainment.

Forgov.qld.gov.au. 2021. Technology and applications for managing records | For government | Queensland Government. [online] Available at: [Accessed 24 June 2021].

Mathioudakis, A., Rousalova, I., Gagnat, A.A., Saad, N. and Hardavella, G., 2016. How to keep good clinical records. Breathe, 12(4), pp.369-373.

Legislation.gov.uk. 2021. Health and Social Care Act 2008. [online] Available at: [Accessed 24 June 2021].

Nhsx.nhs.uk. 2021. [online] Available at: [Accessed 24 June 2021].

https://www.legislation.gov.uk/ukpga/2018/12/contents/enacted