Message from Hertfordshire County Council Integrated Community Support Team:
The Council has received an increased number of queries relating to providers’ use of electronic care records.
We are aware that many of our contracted providers are choosing to use such systems to support their businesses. In order to ensure that this supports the wider health and social care system, along with the provider and service user, the Council has developed the following guidance in consultation with providers, the Hertfordshire Care Providers Association, operational colleagues and the regional network.
Whilst the Council supports the use of such systems, providers must be mindful that going entirely paperless will not be appropriate for every service user and their family/carer and the provider will need to facilitate access to information where this is required, this may for example be by secure email or in some circumstances through continued use of paper versions of diary records etc in the service user’s home.
People using a service must be able to access and contribute to their own records in their preferred format, in line with the Accessible Information Standard.
As a minimum the Council expects the following information to be in a service user’s home:
- A Service User Guide
- A care plan so that the service user and/or their legal representative and any visiting professionals are able to see the care support that an individual has
The exception to this will be where a service user expressly chooses not have paper copies of documentation in their home.
Where providers are working with partners to support an individual’s needs, clear communication methods will need to be agreed and put in place to ensure transparent flow and handover of information.
In an emergency situation, paramedics and GPs will require urgent access to records regarding medication, therefore it is important that a written record continues to be maintained in the home where a provider chooses to record administration of medication using an eMAR sheet.
Providers must ensure that systems are robust and secure with contingency in place should systems go down.
It is not appropriate for service users and their family/carers to incur a charge to access basic care information for example via an app. Service users in receipt of care are financially assessed by the Council and pay an appropriate contribution towards their care service, they should not then be further charged in relation to their service.
Providers will need to evidence that they have discussed choices relating to information and documentation with the service user and their family/carer (where appropriate). It is not sufficient to assume individuals are happy with electronic care records because they have not specifically raised a concern or requested alternative options.
Individuals must be made aware of the options open to them. This will be monitored by the Council through reviews and monitoring visits.
Providers will need to be mindful of confidentiality and steps will need to be undertaken to support the individual to decide who can have access to what information.
Social care professionals and Monitoring Officers employed by HCC will require access to information to support statutory reviews and quality assurance processes. Providers will therefore receive requests for data and information and must respond to these within 24 hours or sooner where requested, to avoid any delays.
If you have any queries relating to the use of electronic care records, please speak to your Monitoring Officer in the first instance.