Using information for reflective practice

It also supports health and care professionals and information governance (IG) professionals to understand how to manage access to people’s information for reflective practice in a lawful and appropriate way.

Reflective practice involves health care professionals taking time to think about an episode of care they provided and the effect this had on the patient or service user. This helps them to learn from their experiences so that they can continue to do a good job, or do a better one if needed to provide better care.

Those caring for you can usually reflect on the care they provided without looking at your confidential information. But there may be times when they do need to look at it, as in the following example:

A case of hidden stroke

Ambulance clinicians were called to help a patient with dizziness and a headache. Because the patient was in good health the ambulance team thought they may have vertigo, which is not urgent and doesn’t normally need emergency care. The team tested for stroke and other conditions, but found nothing unusual. But the patient had high blood pressure and trouble balancing so the team took them to the local general hospital emergency department.

Afterwards, the team started to wonder if they had done the right thing. Had they missed something? Did the patient have something more serious than vertigo?

They decided to look into this as part of their reflective practice. After checking, they discovered that the patient never had vertigo. It turned out that they had suffered a posterior stroke, which doesn’t always show up in regular stroke tests. The patient needed to be transferred to a specialist acute stroke unit.

By reflecting on the case, the crew learned that some strokes don’t show up in the usual way. Now, they are better at recognising the signs of a posterior stroke which might not be identified in a normal stroke test. This means they can respond in the right way by taking the patient urgently to a specialist acute stroke unit for urgent treatment to give the patient the best chance of recovery.

While a health care professional is still caring for you, they are allowed to look at the relevant parts of your record to reflect on the care they are providing. This helps them check that they are providing you with safe, high-quality care.

After you have left their care, if the health care professional needs to see your information to reflect on the care they provided to you, they:

• must add a written note to your record explaining why they need to see your information to reflect on their care
• must show that they need to see your information to deliver safer, high-quality care
• may only look at the relevant parts of your record

Need to look at the information within six months of the care they provided to you. They can only look at it after six months if there is a very good reason.

All health and care services need to explain in their privacy notices what reflective practice is and how your information may be used for it.

If you do not want your information to be used for reflective practice, you have the right to ask those caring for you not to use it. They will note this on your health and care record so it is not used for reflective practice.