Should The Future Recording of Patient's Information Be More Effective?

The future for any professional therapist wishing to encounter vulnerable people with mental health should dramatically change with immediate effect to the benefit of those people they claim to assist, the first conversation will form part of a clients records which will never be removed so if they get it right from day one trust and honesty should always exist in the relationship and few errors would occur.

The person in charge of overseeing records should be the initial face of the organisation that contacts the new incumbent to the service and should undertake vigorous checklists from the very start to ensure no errors would arise in the future.

Therapy should not be allowed to start until this conversation has taken place and if it does a therapist should be disciplined, look at treating a patient like your induction at work.

The relevant organisation should undertake a signed questionnaire covering these issues so it is clear how both parties should operate and there are no misunderstandings.

Communicating with patients

• How would you like to be contacted: email, mobile, post, home phone?
• Is there any method we should not use in order for us to be sensitive to your circumstances?
• Are your family supportive of you receiving this treatment from us and are there any times which you are unable to attend appointments for reasons you may or may not wish to disclose to us at this stage?
• When is the best time for us to contact you?
• Is it in the patient’s best interests that all phone and face to face conversations are recorded to reflect dialogue between both parties a necessary requirement for the future to safeguard both parties? 
• What happens if people cannot attend appointments; should a joint signed agreement be made to the reasons this was not possible to participate on that date & time so it is accurate and cannot be construed patients are denying appointments and may address any underlying issues that relate to this matter?

General records management

It has always been my view that a person should be shown actual documents they use to record information either on paper or print screens from a computer with an explanation of any clinical terms that the patient may not understand; any notes taken during a session a person could sign them then or when they are typed up so they agree with the summary of the meeting as pivotal in general records management for the future as standard practice.

• Does the patient wish to access their records periodically i.e. monthly, quarterly or annually?
• Does the patient know what laws cover the information kept relating to medical records?
• Does the patient understand how long records will be kept for?
• Who has access to the patient’s records?
• Should a patient be given a feedback form that at any stage they can place on record if they felt the therapist was pushy, intimidating that this can be picked up to avoid putting the patient through an ordeal in the form of a complaints process which may do more harm than good at the start of the relationship?
• Does the patient have a copy of the organisations data management / safeguarding policy or other relevant policies?
• Does the patient understand what to do if they feel information is misrepresented, inaccurate in accordance with laws that govern information management?
• Does the patient understand that records can never be deleted?
• What if records will not be released would a statement be given to the nature or reasons why this may not be granted?
• Could the refusal of information cause more harm than good for the patient concerned?

Travel expenses

• Is the patient aware they can (Subject to qualifying criteria) claim for travel expenses and are aware of the process for doing so?
• Should the mental health organisation make the effort to make the patient aware of this and record they have notified them of such schemes available as best practice for the future?
• Does the organisation have any forms or information they can pass to the patient especially if they are on low income or state benefits this could assist them greatly getting to appointments?
• Should a person need to claim these expenses from the organisation in accordance with NHS guidelines where and who would they go to subject to terms and qualifying conditions to receive this payment?

Communication between organisations

Should information need to be shared between organisations will the person be informed i.e. between a GP and Mental Health organisation or shared with social services if they are a risk to themselves or others; will they be notified prior to action being taken in order that the person taking this action has interpreted what information they wish to share is correct and in context?

Does the patient understand that information can be shared even if it is without their consent & awareness only to find out later when something occurs out of the blue may destroy any trust built with the patient over time because the therapist did not disclose these to the person?

Formal diagnosis of illness

• Should a therapist diagnose a person if they have a disability related to mental health and this be placed on their medical record as standard practice now not in the future?
• Should a formal letter be issued to the person concerned to verify their disability on headed paper for related matters such as employment and this is reviewed after a period of time i.e. 6 months?
• How would this work in practise and would more than one therapist be required to verify their condition?

Future recording of records

It is my understanding that in the near future anyone working with clients suffering from mental health in the NHS will place a patients records online with secure login arrangements so a patient can access their records 24 hours a day 7 days a week i.e. any information held electronically or on paper on data bases, letters, phone calls, appointments i.e. basically anything to do with the person.

This should be extended and used as best practice to all people encountering those with mental health, this will make professionals in the future more accountable when they know anything they write on someone will be instantly published for the client to access should they so desire.
The sooner this occurs with an efficient IT system in place the better for the patient putting the customer first not staff each and every time and sufferers should be consulted at each individual place what information, how its presented etc and have significant input into this matter.

This will save people having to make subject access requests which may or may not be granted, printing off huge amounts of paperwork emails, letters if it is managed efficiently in date order will benefit everyone. I am sure those highly paid and creative people in IT can  develop systems to make it easy for all those involved in patients records.

The above information and how it is managed is paramount so the sooner that those who manager patients with mental health are totally honest, do not withhold information greater degrees of trust can be gained and the levels of secrecy which exists expires then a faster process of therapy and engagement can occur between all relevant parties and a more successful outcome can arise for the person concerned.

Conclusion

Therapists are keen to document information shared however try and access what they put and compare it to what was actually said, like Chinese whispers, and this will judge their verbal comprehension abilities to document this in written form. If they don’t record anything then there is never anything to contest.

There is a deep sense therapists will not be held accountable for what they write for fear they could be liable for falsifying records, a person should have the right to talk about something but if it’s very sensitive it’s not recorded, people may not share things as they don’t want others to read about it so discretion surely is required if they are able, matters raised in this article need to be readdressed and questioned locally, regionally and nationally for things to be more effective.

There is a balance to be made about the patient receiving treatment, someone delivering it and how information about what is said in actual sessions, how in-between correspondence is recorded (verbally, email, text and in letter); managed and interpreted but the patient reaching a satisfactory mental frame of mind at the end of the process should be at the centre of all of this.

This increase in work should not be seen as unnecessary paperwork, waste of time but constructive and an essential part of the therapy process so there are no misunderstandings later down the tracks i.e. staff leave or cannot recollect saying the things documented but were apparently said so ongoing review of records maybe time consuming due to volume of patients but if managed effectively should be built into the management of patients care which is voluntary but perhaps should be mandatory.

One solution is to perhaps give the unemployed work experience to assist with an increase in workload or in a 1 hour session build in 10 additional minutes to review what they therapist has written about them.

Patients and the organisation should sign a joint data agreement policy from day one before any therapy commences which would include but not conclusive of the following issues above.

Mark Crossley BA(Hons)