As a practitioner you will be expected to record some information as part your job. This includes work history, medical, skills, assessment, personal and other information. Consideration of confidentiality will need to be observed all the times. This might involve controlling access and securing documents. (using passwords on memory sticks and computer systems, locking away documents). Some information might be sensitive and subject to reporting requirements especially when safeguarding is involved.
Your records should be accurate, relevant, clear, auditable and serve a purpose. The information will need to be passed to the appropriate people within timescales expected. You should bear in mind that people who use your services have the right to access information you hold about them inline with Data protection laws and GDPR regulations.
You need to ensure you have sought consent to record and store certain information from the people who use your service. Consent should also be gained in order to share information with others. There is however times when you can disclose information without consent in cases of terrorism and situations resulting in harm.
Ensure you follow your own organisational procedures and policies regarding how you record and handle information. You might have dedicated specialist forms or database systems in place. These will need to be used to ensure you are recording the correct information. Stay away from jargon and personal views when recording information. The information should also be up to date, complete and legible. You might need to review certain information and ensure dates and signatures are recorded.
No access should be given to anyone who is not authorised. Your organisation might also require you to use specialist shredders and confidential waste bins. These resources are in place for a reason. You should not be seen using normal bins or leaving information lying on desks. The information commoner has fined a lot of organisation for breach of data. Beaches of data has a lot of consequences on your own organisation including financial impact as already highlighted above. You might lose your job for breaching the conditions of your employment. There should also be consequences as a result of bad reputation. People who use your services might lose trust in you and your organisation.
Ensure you attend any training or courses available to you, which might make it easy for you to fully understand your responsibilities when it comes to recording of information systems and procedures. You could also shadow others so that you can observe and learn how information is used, shared and recorded.
Remember information should be privileged and can only be shared on a need to know basis. When not sure of how to handle information please ensure you seek advice and guidance from a senior member of your organisation.