Stage 2 – Recording needs
Once information and communication support needs have been identified, they MUST be recorded in a clear, unambiguous and standardised way; electronically or using paper records.
“In big hospitals you can get lost, it’s very easy to get lost because you don’t know how big the hospital buildings are.”
Where service users have information and/or communication needs caused by a sensory impairment or loss through learning disabilities:
It is the responsibility of the IT systems supplier or organisational lead to ensure that all electronic coding used is current and up-to-date.
Systems and documentation MUST be formatted so information records are ‘highly visible’.
Organisations should ensure that where communication support needs are recorded, they are accurate and up-to-date. Edit checking and quality assurance of data MUST be in place, including alerts/mechanisms to prevent staff from recording mutually incompatible data in related fields. Examples of mutually incompatible subsets include are where a service user needs braille; the person will therefore not lip-read (because use of braille implies a significant visual loss, whereas lip-reading relies on some use of sight).
The Specification makes clear that where online systems enable patients or service users to access their own records (subject to Data Protection Act 1998 safeguards), such systems:
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Conversely, some combinations of recorded needs can occur, for example, ‘patient uses a hearing aid’ and/or ‘lip-reads’ plus ‘requires contact through short message text message’ or ‘contact by email’.
Staff should consider all these aspects to record individuals’ needs and when prompting to identify communication needs.
Data communications needs may be deliberately used in combination and/or with appropriate additional free text to support clarity, and where supported by relevant local policies. For example, the combination of ‘using British Sign Language’ and ‘requires information on digital versatile disc’ indicates the individual needs a British Sign Language (BSL) video saved and sent to them on DVD.
The service user should be made aware of information recorded and periodically be asked to verify its accuracy.