Sheffield Health and Social Care NHS Foundation Trust Psychological Therapies Governance Committee A protocol for using electronic notes in psychological therapies (talking treatments) Review version June 2016 1
A protocol for using electronic notes in psychological therapies (talking treatments) Contents 1. Rationale 3 1.1 Reference Group 4 2. Aims of the protocol 5 3. Trust Policy 5 3.1 Content of clinical record notes 5 3.2 Trainees 6 3.3 Exceptional confidentiality 7 3.3.1 Password protected Word documents on Insight 7 3.3.2 Risk Management 8 3.3.3 Encrypted documents and trainees 8 4. Duty of care 9 4.1 Detail in psychological therapy notes 9 4.2 Cross-referencing 9 4.3 Need to know 9 5. Information management 10 5.1 Process notes 10 5.2 Supervision notes 11 5.3 Therapeutic tools 11 5.4 Records of group process 11 5.5 Art work 11 6. Treatment of old notes 12 7. Confidentiality and consent 12 7.1 Confidentiality and complaints management 13 8. Clinical records and research 14 9. Computer access and training 14 10. Further actions 14 11. Links with other SHSCT policies 15 12. Appendix 1 Supervision record proforma 16 2
A protocol for using electronic notes in psychological therapies (talking treatments) Executive Summary All psychological therapists (psychotherapists, psychologists, counsellors, arts therapists and other talking treatment practitioners) working into SHSC service directorates are expected to include all information from therapy sessions (that is relevant to patient care) in the shared clinical record for the service in which they are based. In most cases these will be electronic patient record files, however in those areas where electronic records are yet to go live, the spirit of the advice in this document still applies. 1. Rationale Because this protocol is based on the SHSC Electronic Records Mandate (see http://xct/index.php/e-records-mandate-medicalrecordsmenu-1109.html) it refers throughout to the Insight electronic clinical notes system, though it is recognised that some workers in the Trust contribute to other electronic notes systems, or are awaiting the roll-out of Insight. The Records Management Policy (SHSC: 2013: p8) states the Trust s commitment to ensuring that there is a single electronic care record (the Insight System) for service users in all areas of care. It identifies that accurate, accessible care records are essential for providing; safe, effective, high quality evidence based treatment and care to service users. The document underlines the function of care records as a means of communication between practitioners and the service user. This highlights the necessity that all care record information must be accurate, current, contemporaneous, comprehensive and concise, and must contain a record of; the relevant findings in the health and care of the person receiving the treatment or care and should provide clear evidence of the care planned, the decisions made, the care delivered and the information shared That these records may also be relied on as evidence in court emphasises the need for reliable records and excellent governance. 3
Alongside this duty of communication, all staff have a duty of confidentiality towards service users explained in the Confidentiality Code of Conduct (2009:p8). All are expected to only access clinical material where there is a demonstrable need to know. The Insight clinical records system is being rolled out across all areas of the Trust. The Electronic Records Implementation Plan (2008-2013) required the phasing out of all paper clinical records, the adoption of electronic notes practice, and the transfer of all paper records by scanning on to the system. Prior to this policy a mixed economy of paper and electronic practice existed. Given that all staff must have the complete record available to them when needed, a process of scanning old paper records has been implemented. Access provision is being made in respect of historic confidentiality agreements between psychotherapists and service users. See Treatment of Old Notes (p12) Currently psychological therapists, from all disciplines, across the Trust have adopted the practice of keeping electronic notes. Because they provide settings where service users can reflect in depth, on highly personal, and often unresolved matters, there is a specific need for clarity regarding governance. 1.1 Reference Group This reviewed policy supersedes the Protocol for Electronic Notes in Psychological Therapies (2010). Both versions have been developed in consultation with; psychological therapists from a range of modalities CMHT Managers, Psychological Therapies Governance Committee Information Department Care Records Group Corporate Affairs Patient and Public Involvement Department Reference is also made in the development, to relevant SHSC policies, and a range of professional and Department of Health guidelines. 4
2. Aims of the protocol To promote good communication for care and safety of service users. To ensure the protection of tentative or unresolved material from psychological therapy sessions. To assist the process of gaining informed consent to psychological therapy 3. Trust Policy It is Trust policy that health care professionals hold all information relevant to the care of service users in the Insight electronic clinical record. All psychological therapists are expected to input records of their sessions and all interactions connected with client care on to Insight. 3.1 Content of clinical record notes The Insight clinical record is a contemporaneous account, by all staff involved with the service user, of all matters relevant to their care. Notes should be written in a manner that assumes that the service user may request to see them at some point under the terms of Access to Records at http://shsc.nhs.uk/service/medicalrecords/ (which can be found under Help for Service Users on the SHSC public website www.shsc.nhs.uk Clinical notes are accessible to all staff with a need to know all access leaves an audit trail. Unauthorised access is a disciplinary matter The Insight record should include; The date, time and location of session The type of therapy Consent to therapy Service user s history An account of the contact Any concerns about the service user s health and wellbeing Risks to the service user or other persons Any child protection concerns 5
Outcomes of assessments, formulations, decisions and clinical reasoning, Actions arising Details of communications and advice received All other contacts, phone calls, answering machine messages, e-mails, faxes, letters, handwritten notes, or texts should also be entered onto the electronic record directly, or by scanning or uploading. Other types of clinical record Other materials, for example diagnostic tools, formulations, outcome measures, diagrams, charts, CAT maps, clinical photographs, and letters from clients should be scanned or uploaded to Insight and held in the documents area. In the event of a case for exceptional confidentiality (see below at 3.3), these may be held as password protected Word documents. These items must be crossreferenced to the main clinical record. Therapists are accountable to line managers, professional leads and the Trust s Information Department for the use of this facility which will be audited. Guidance on the use of password protected Word documents is found below at 3.3.1. Audio files should be stored in locked cabinets, or on encrypted memory sticks. Arrangements relating to artwork made by service users in art psychotherapy are outlined at 5.5. 3.2 Trainees In common with all trainees in the Trust, Insight notes written by psychological therapy trainees will be countersigned afterwards by qualified members of staff. Further guidance on note writing is available from the professional associations, from team training within SHSC, and from the Records Management policy 6
(SHSC: 2010: p29) which contains a detailed trust-wide audit tool for electronic notes. 3.3 Exceptional confidentiality It is expected that all psychological therapists will primarily record their work with service users in the Insight clinical record where it can be accessed by all clinicians working with them. Exceptional confidentiality can be defined, as highly sensitive, tentative or unusually detailed material from psychological therapy sessions that is not directly related to the health and safety of or provision of care for the service user. In exceptional circumstances, material requiring particular confidentiality can be included, following agreement with the therapist s line manager or professional lead, in the documents section of the main clinical record in the form of a password protected Word document (see 3.3.1). These documents must always be crossreferenced with a note in the main clinical record. They will then only be accessible to clinicians with whom the author chooses to share the password. Process notes and supervision notes are addressed in Information Management at 5.1 and 5.2 below. 3.3.1 Password protected Word documents on Insight In case of a need for exceptional confidentiality, where a discussion with line manager/or professional lead outlining the reasons for the request has taken place and been documented, therapists can apply for permission (via the Electronic Forms portal on the Trust Intranet) to create a password protected Word document. This must then be saved to the documents area of Insight with a cross reference in the shared clinical record. This allows for the document to be locked to the creator s service team or professional grouping. Ordinarily these will only be accessed by the author, but the 7
group tag allows for permissions to be obtained in case of clinical emergency or any other exceptional need for disclosure in the author s absence (for example on leave, moved on, retired). 3.3.2 Risk Management To manage the risk of clinical notes being password protected, the password must be registered with the Information Department via the appropriate electronic form. This allows access to be obtained, if needed, in the author s absence. The use of password protection will be audited by the Information Department. The psychological therapist s line manager or professional lead will review the therapists need for this type of document in supervision. These additional documents will form part of the whole clinical record, but will only be accessed by those who have been given the password by the author or the Information Department in their absence. Information held under these arrangements must always be cross-referenced to the main clinical record. Any information connected with the treatment, care and safety of service users, children or others must primarily feature in the main clinical record and not be password protected. Any information that other clinicians may require to fulfil their responsibilities must not be stored solely in password protected documents, audio or video files, or on paper. Information governance and limits to confidentiality should be discussed with service users as part of the consent process. Information leaflets for service users are available on the Trust website. 3.3.3 Encrypted documents and trainees The Trust does not consider it appropriate for trainees to create password protected, Word documents. All their notes will be made on the electronic record and countersigned by their supervisor. Their process notes may be kept in paper form provided that they are anonymised (see 5.1) 8
4. Duty of care Duty of care requires that all the actions of a health care professional are directed towards the wellbeing of the service user. Clinical notes must clearly demonstrate how the care provided fulfils this duty. 4.1 Detail in psychological therapy notes The degree of detail of psychological therapy notes in the main electronic clinical record will vary according to the therapist s evaluation of; clinical need, the therapeutic modality and process, the assessment of risk to the service user or to others, the protection of children and vulnerable adults, any exceptionally sensitive matters not related to duty of care, and multi-disciplinary colleagues need to know. Therapists are encouraged to make concise notes that inform a team approach. SHSC (2010) Records Management Policy provides a generic trust-wide audit tool for clinical record notes. An outline of basic content for psychological therapy notes appears at 3.1 above. 4.2 Cross-Referencing Provision for exceptional confidentiality is outlined above at 3.3 and 3.3.1. As stated, this additional material will be cross-referenced in the main clinical record. For example; a more detailed record of (modality) therapy sessions for this service user exists, it is kept as password protected Word documents in the clinical record for reasons of particular confidentiality by (name and designation) in (location) Permission for access is via the author, their professional lead, or the Information Department. 4.3 Need to know All Insight users are required to only access care records on a need to know basis. 9
The author is responsible for deciding if other clinicians require access to their password protected documents and for sharing the password in such cases. Both neglect to share information under duty of care, and breaches of confidentiality, have serious disciplinary consequences. These are described in the SHSC Confidentiality Code of Conduct (2009). See Links with other Policies below at 12. 5. Information management As well as notes for the clinical record, some psychological therapists also keep process notes, supervision notes, group notes, maps and diagrams, therapeutic tools, 2 and 3D artworks, clinical photographs, DVDs and audio files. 5.1 Process notes Some psychological therapists write process notes as well as clinical notes. These can be defined as the optional reflective tools to help with processing some of the less conscious material from sessions. This is in the interests of assisting the service user with difficulties that are psychodynamic in origin. In the psychoanalytic tradition of free association, some therapists write about the counter-transference, i.e. their feelings, and responses to the service user s material, which they then draw on in clinical supervision to assist with understanding the dynamics of the therapeutic relationship, and with quality control. Some make reflective drawings and diagrams for the similar purposes. These by nature are highly subjective accounts for the purpose of assisting the therapist s learning and development, and as such are not of value to other clinicians involved in the service user s care. Process notes should never be a substitute for clinical notes and must never contain any information relevant to care that does not also appear in the main clinical record. 10
Where kept these should be labelled as process notes, anonymised and held separately from the clinical record. 5.2 Supervision notes Supervision notes are also required to be kept by the supervisor and the supervisee under the terms of the SHSC Supervision Policy (October 2014:24) These should be either held electronically, or in a locked cabinet using, as a minimum, the standard form (see below for the template at Appendix 1). Where relevant to the care of a service user, advice given by a supervisor should be identified as such, and referred to in the service user s clinical record. Supervisors are also required to keep sessional notes which must also be kept under confidential conditions. 5.3 Therapeutic tools Charts, maps, diagrams, outcome measures, formulation letters and other therapeutic tools should be scanned onto Insight for inclusion in the documents section of the notes. Where documents of this type are particularly sensitive, for example, clinical photographs, they can be stored as password protected Word documents by agreement with the therapist s line manager (see 3.3 Exceptional Confidentiality) Audio files used for research and training have particular rules governing consent and disposal is outlined by the relevant Training Organisation. The SHSC Confidentiality Code of Conduct (2009:20) gives the following advice; shredding, the use of confidential waste boxes, and the destruction of hard drives as examples of disposal methods for confidential waste. For more detailed guidance on retention and disposal, see the Department of Health s NHS Code of Practice Part 2 (2009) which is available in the policies area on the SHSC Intranet. 11
5.4 Records of Group Process A record of group sessions is entered onto each individual member s clinical record, with particular care not to disclose of third party information. 5.5 Art work Art works made by service users in the context of art psychotherapy or other psychological therapies can be regarded as subjective records of an unfolding process, and as such are context-specific and open to interpretation. Recordings made of music therapy or dramatherapy can be regarded in a similar way. This makes them highly ambiguous if taken out of context in clinical or brought into legal settings. The British Association of Art Therapists recommend that artwork made during therapy should be treated with equal security to other confidential client information. Where clinically appropriate, with the service user s agreement, photographs of artwork can be scanned to Insight or retained on an encrypted memory stick and stored in a locked drawer. At the end of therapy service users are invited to keep the work themselves, at which point it ceases to be part of the clinical record. Where they choose not to retain their work, it will be retained under confidential conditions, to facilitate those who may wish to access it at a later date. It may be kept in either physical or digital photographic form (BAAT: 2014:7) for a period in line with Department of Health Guidance (2009:33-34). The main Insight clinical record is the best means of providing lasting evidence of therapy of this nature. Art psychotherapists keep images confidential during the course of therapy. The service user may choose to disclose their artwork to others, although awaiting the end of art therapy is usually encouraged. A guideline on good practice in exhibiting service users art-work exists is available from the SHSCT Arts Lead via Therapy Services. 12
6. Treatment of old notes. Historic psychological therapy records including notes, diagrams, tools, reports and other documents from all areas are being scanned onto the Insight system. In respect of former agreements around confidentiality, and the requirements of Information governance, these are now locked and tagged to the therapist s clinical team, or professional grouping. This means that those with a need to know will seek permission from the individual who created them. In their absence, anyone requiring access would contact the clinician s team manager in the first instance. 7. Confidentiality and consent Confidential information should only be used for the purpose it was provided, which the individual has been informed about and has consented to unless there are exceptional circumstances. The SHSC Confidentiality Code of Conduct (SHSC: 2009:13) outlines circumstances where information may need to be shared without consent e.g. where there is risk to the service user, another person or a child, or there is risk of a serious crime. Users of psychological therapies require clear, unambiguous information about confidentiality, psychological therapies notes governance, and the limits to confidentiality. Consent to receive therapy will be informed by this understanding of shared electronic information practice. Existing SHSCT guidance leaflets e.g. Confidentiality and Information Sharing: Information for Service users and Carers (2014) deal with good practice around confidentiality and its limits. Explaining consent and information management should take place at the first meeting between therapist and client, and will be helpful in the process of gaining informed consent for talking treatments. Where required, a form of words should be devised in consultation with the Patient Public Involvement manager in accordance with the SHSCT (2008) Policy for the Development of Information for Service Users and Carers which is available on the Trust Intranet. 13
7.1 Confidentiality and complaints management Confidentiality requires that clinical record notes should not contain reference to complaints which the client has made or is considering making to SHSCT. All complaints correspondence must be held separately from the clinical record. (Complaints Procedure 2012:7). 8. Clinical records and research Guidance from the Department of Health underlines that in research other than the clinical trial of medicines, good practice requires the keeping of properly maintained and approved separate research records, but that the researcher should ensure that vital information about the patient s clinical condition, treatment and special characteristics (e.g. allergies) is replicated in the main, formal care record (Donaldson, L: 22/06/2009: Gateway Reference 11985: DOH) 9. Computer access and training Insight training is a priority for all talking treatments practitioners. All managers are responsible for ensuring their staff are aware of their record keeping and records management responsibilities, and that they are equipped to fulfil them. This will include covering records management in corporate and local induction, and identifying and meeting specific or generic training needs through personal development plans. Therapists will require sufficient computer access This will mean that mean that some existing computer and desk sharing arrangements will require review, and additional equipment purchased, Access to work needs must be assessed and met under the Disability Discrimination Act. Managers also have a responsibility to ensure that staff with disabilities, and difficulties such as dyslexia are able to comply with the policy by 14
arranging for reasonable adjustments, such as work station assessments and accessible and specialized software. Specific note-keeping and the law training Team training on notekeeping will be required to take into account a range of differing processes and practices amongst multi disciplinary teams and within the range of psychological therapies. Impact of new technologies on Information Governance This requires assessment at the planning stage. 10. Further Actions For review 2019 11. Links with other SHSC policies and guidelines Complaints Policy (2012) Confidentiality Code of Conduct (2009) Electronic Records Implementation Plan: Part of the Information Management and Technology Strategy 2008-2013 Electronic Records Mandate 2011 Policy for the Development of Information for Service Users and Carers (2008) Protocol for Electronic Notes in Psychological Therapies (2010) Records Management Policy (2013) Safeguarding Children. (Dec 2014) Safeguarding Vulnerable Adults. (June 2014) Supervision Policy for Health and Social Care Staff. (2014) Waste Management Policy 2014 Laura Richardson Professional Lead for Arts Therapies With many thanks to all those who helped. March 2015 15
Appendix 1 Supervision record proforma (SHSC Supervision Policy: 2014:p20) Record of Clinical Professional Supervision This is the minimum requirement for record keeping and this document must be available for audit purposes. Additional guidance and recording requirements may be required by directorates and teams, and these forms should be kept by the supervisee. Name of Supervisor Name, Role and Work Area of Supervisee Date Supervisor signature Supervisee signature Topics discussed Comments 16
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