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Posted by Helen Brackenbury, Jun 22 2011 11:23AM

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Client records

I'm thinking I'd like to join the 21st century and keep my client records on the computer. Can anyone recommend a system (which doesn't cost too much)?
Giuseppe Tomaselli
Jun 22 2011 12:21PM
Hi Helen,
The following guidelines from the Department of Health may be of use to you as more than the right program (which you can realy design yourself by using Words) it is the legal implication you should be aware of.
The Data Protection Act 1998 gives patients and clients access to their paper-based and computer-held records. It regulates the storage and protection of patient and client information held on computer. Its remit also includes access to the health records of living people, and patients’ rights to have inaccurate information corrected.
Safeguards for computer-held records must be in compliance with the
Computer Misuse Act 1990. The principle of the confidentiality of information held about your patients and
clients is just as important in computer-held records as in all other records,
including those sent by fax. You are professionally accountable for making sure that
whatever system is used is fully secure. Clear local protocols should be drawn up to
specify which staff have access to computer-held records. Although patients and
clients can expect their health records to be accessed by different members of the
inter-professional health care team, this should only be done where necessary.
Patients and clients do not have the right to limit the amount of information
relevant to their care or condition that is incorporated in their records. However,
they can limit access to certain information about themselves and you must respect
their right to do so. Local guidelines and protocols should address this right and
these procedures should also include ways of establishing the date and time of any
entry, the person who made the entry, and should ensure that any changes or
additions to entries are made in such a way that the original information is still
visible and accessible.
References
Access to Health Records Act 1990 – Department of Health. The Stationery Office,
Norwich, www.hmso.gov.uk
Caldicott Report 1997 – Department of Health. The Stationery Office, Norwich,
www.hmso.gov.uk
Computer Misuse Act 1990 – The Home Office. The Stationery Office, Norwich,
www.hmso.gov.uk
Data Protection Act 1998 – The Home Office. The Stationery Office, Norwich,
www.hmso.gov.uk
Freedom of Information Act 2000 – The Home Office. The Stationery Office,
Norwich, www.hmso.gov.uk
Human Rights Act 2000 – The Home Office. The Stationery Office, Norwich,
www.hmso.gov.uk

Best Regards,

Giuseppe
Angelina Kelly
Jun 23 2011 9:52AM
Hi Helen,

Thanks for highlighting this issue.

Thanks Giuseppe for this very valuable information.

I think I'll stick to paper files.


Regards

Angelina

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