Audit of Practice Around Record Keeping and Partner Notification Maeve Cross & Martin Murchie

Aim To explore routine practices in relation to record keeping and partner notification To explore routine practices in relation to record keeping and partner notification

Audit January to July 2010 January to July 2010 Survey Monkey – on line questionnaire Survey Monkey – on line questionnaire Cascaded through Cascaded through –SSHA (Including SSHA Reps) –BASHH –Chlamydia Screening Co- ordinators –GUNA –Local networks throughout UK. –Open to all health care professionals who carry out partner notification.

What did we ask? Which country in the UK? Which country in the UK? Identify your discipline? Identify your discipline? Where do you record PN? Where do you record PN? Can PN details be removed? Can PN details be removed? If details in clinical notes how are they recorded? If details in clinical notes how are they recorded? What legislation/guidance informs practice? What legislation/guidance informs practice? What is a verified hard outcome? What is a verified hard outcome?

Results

Who took part? 46% Sexual Health Advisers 46% Sexual Health Advisers 15% Specialist Sexual Health Nurses 15% Specialist Sexual Health Nurses 20% Chlamydia Screening Co-ordinators 20% Chlamydia Screening Co-ordinators

Where from in the UK? Northern Ireland 2% Northern Ireland 2% Scotland32% Scotland32% Wales 1% Wales 1% London14% London14% Rest of England 53% Rest of England 53%

Disciplines N Ireland 3 Participants – 1 SHA / 2 Nurses Scotland 54 participants – 11 SHA / 23 Nurses / 20 medics Wales 1 participant – 1SHA London 25 participants – 15 SHA / 9 Chlamydia Rest of England 89 Participants – 52 SHA / 28 Chlamydia

How are contact details recorded? 68% of participants document full name and clinic number, with 17% documenting full name or clinic number. 68% of participants document full name and clinic number, with 17% documenting full name or clinic number.

What is a hard outcome? Majority of participants said that a verified outcome was when you can confirm with their own service or another service that a contact has attended. Majority of participants said that a verified outcome was when you can confirm with their own service or another service that a contact has attended. Though 42% of participants also said that a verified outcome was also when the index client had informed them their contact had been tested and treated even though this could not be confirmed or verified with a service or health care provider. Though 42% of participants also said that a verified outcome was also when the index client had informed them their contact had been tested and treated even though this could not be confirmed or verified with a service or health care provider.

Is information from Index enough? N Ireland 67% Scotland 21% Wales 100% London 69% Rest of England 45%

Can contact information be removed? 53% of participants said yes contact information can be removed from clinic notes 53% of participants said yes contact information can be removed from clinic notes 17% said No that contact information could not be removed. 17% said No that contact information could not be removed. The 30% of participants who chose other said The 30% of participants who chose other said Not stored in main clinical notes (Ledger, PN sheets) Notes electronic Don’t know (3) Details blanked out when copying.

What guides us? Most common re-occurring response was that of Data Protection followed by VD regulations and Local Policy. Most common re-occurring response was that of Data Protection followed by VD regulations and Local Policy. Wide range of Policies and Guidance used. Wide range of Policies and Guidance used.

Key Documents Data Protection Act 1998 Data Protection Act 1998 – regulates how personal information is processed, i.e. everything that is done with it. – regulates how personal information is processed, i.e. everything that is done with it. “The organisation should have procedures in place setting out ‘need to know’ access controls alongside processes…..for each member of staff” ( NHS Information Governance, 2007) “The organisation should have procedures in place setting out ‘need to know’ access controls alongside processes…..for each member of staff” ( NHS Information Governance, 2007)

The NHS Trusts and Primary Care Trusts (Sexually Transmitted Diseases) Directions 2000 The NHS Trusts and Primary Care Trusts (Sexually Transmitted Diseases) Directions 2000 allows for info to be processed with a view to - controlling and preventing the spread of such diseases and risks allows for info to be processed with a view to - controlling and preventing the spread of such diseases and risks “…organisation's must ensure that they have processes in place to ensure that such information is available only to those permitted access” NHS Information Governance, 2007 “…organisation's must ensure that they have processes in place to ensure that such information is available only to those permitted access” NHS Information Governance, 2007

Other guidance The Manual for Sexual Health Advisers, SSHA, 2004 The Manual for Sexual Health Advisers, SSHA, 2004 Human Rights Act 1998 – respect for private life Human Rights Act 1998 – respect for private life Confidentiality: NHS Code of Practice, Department of Health Confidentiality: NHS Code of Practice, Department of Health Codes of Professional Conduct – GMC, NMC, SSHA Codes of Professional Conduct – GMC, NMC, SSHA Confidentiality: NHS Code of Practice, 2003, DoH Confidentiality: NHS Code of Practice, 2003, DoH

Clarification or confusion? “Information provided in confidence should not be disclosed in a form that might identify a patient without his or her consent” Confidentiality NHS Code of Practice DoH 2003 “Information provided in confidence should not be disclosed in a form that might identify a patient without his or her consent” Confidentiality NHS Code of Practice DoH 2003 When a contact’s details are obtained, often we don’t have their consent – what principles justify holding that information? When a contact’s details are obtained, often we don’t have their consent – what principles justify holding that information?

Principles underpinning practice Caldicott principles result of Caldicott Report (1997) Caldicott principles result of Caldicott Report (1997) Justify the purpose(s) for using patient data Justify the purpose(s) for using patient data Don’t use patient-identifiable information unless it is absolutely necessary Don’t use patient-identifiable information unless it is absolutely necessary Use the minimum necessary patient-identifiable information Use the minimum necessary patient-identifiable information Access to patient-identifiable information should be on a strict need to know basis Access to patient-identifiable information should be on a strict need to know basis Understand and comply with the law Understand and comply with the law

Summary/What next. “Systems and processes should ensure that employees only have access to those parts of the record required to carry out their role” NHS Information Governance – Guidance on Legal and Professional Obligations DoH 2007 “Systems and processes should ensure that employees only have access to those parts of the record required to carry out their role” NHS Information Governance – Guidance on Legal and Professional Obligations DoH 2007 Is there a need for more clarity for health advisers on where/how to record and store contact information? Is there a need for more clarity for health advisers on where/how to record and store contact information? Paper lite systems – a help or a hindrance in encouraging collection of contact data? Paper lite systems – a help or a hindrance in encouraging collection of contact data?

Questions?