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W3C-validated transitional XHTML 4.13 The process: Record keeping
What
records should you keep?
Ideally, prescribing organisations or individuals should keep records of information they have issued, and any concerns that patients or carers raised during consultations. These could, for instance, be a part of electronic patient and social care records.
Only a few of the 20 pilot sites have been able to achieve this level of record keeping. Furthermore, the whole area of record keeping raises issues of confidentiality, especially when recording is extended to voluntary agencies or care settings where clients are advised anonymously. If patient records kept by the variety of agencies involved in care cannot readily be shared, this will greatly affect the ability to view information offered to patients and carers at different points in their journey.
If directories are linked to electronic patient record systems, there may also be difficulties with arranging for patients to gain direct access to these. And, of course, IP systems that encourage self-prescribing and dispensing will find it hard to keep records of the information that individuals have found themselves.
Nevertheless, the pilot sites recognised that, in the longer term, records of information prescriptions issued, what they contained, any concerns raised in consultations and also whether the IP had been taken up and acted upon should all be part of electronic patient and social care records. This will support continuity of care – especially when patients and carers are increasingly being referred between a variety of local organisations and support agencies for their care. And sound record keeping will also ensure that the value of information prescriptions can be monitored effectively.
In future it is expected that information prescriptions will form an integral part of the care planning process and therefore 'information needs' and a summary record of 'information delivered' will be recorded on the care plan. Future systems that have an electronic integrated care record will contain an IP record as part of the care plan. When developing your own local record-keeping systems, you should consider how you could plug into these national developments as and when they are introduced.
The main forms of record-keeping adopted by the pilots so far:
- No record kept
- IP offered is recorded in patient notes
- Paper copy of information prescription kept in patient notes
- Information prescription and contents recorded electronically in patient notes
- Record of information dispensed by third parties kept remotely
Amongst the pilot sites, the use of IT to record the issuing of IPs was quite basic: usually the simple recording on a spreadsheet of the number of prescriptions issued. Some sites manually recorded IPs on a patient record or case management system. Others recorded the items issued – but no personal history – mostly so that they could derive an analysis of the process.
Sites which chose not to record IPs electronically chose either to keep no record, record the fact an IP was issued, but include no detail of the content, or store a paper copy of the IP in the patient's records.
Ways of including IPs into existing processes and records
There are many ways to make sure IPs become part of the standard processes for recording information. For example, Darlington is adding a prompt – to note that an IP has been issued – to the Annual Health Check forms already in existence in primary care. The new user information system which is being launched in Leeds Mental Health Trust will include fields for information prescribing. Oxleas IPs are being tailored to the already established Care Plan Assessment (CP), and the information requested and dispensed will be recorded on the Care Action Plan (CAP). The Isle of Wight and Oxfordshire sites are both linking their IP recording process into the SWIFT system.
The Heart of England pilot site had an IT specialist write software that allows for the collection of contact data. The attached document shows screenshots of the various screens used to record a contact.
Many pilots identified the need for IT to support their activities: this is discussed in the Final Report of the Evaluation of the Pilot Programme, especially in Appendix 4. You can download a copy of this from the 'final report' page of the main IP website.
On the next page: some of the ethical issues you may encounter
