Using information for reflective practice guidance for health and care professionals

If you are a regulated health care professional, you are required to engage in reflective practice as part of your professional regulation. This guidance supports you and your supervisors to understand whether access to confidential patient information is justified in each case.

For detailed information on the reflective practice process, refer to guidance issued by your regulator we have provided some further information. 

While you are still caring for an individual, you may access relevant information about them for your reflective practice. This may be done on the basis of implied consent for individual care.

There may be times when, to maintain safe, high-quality care, you need to reflect on the treatment you gave someone who has since left your care.

Whilst reflection can often be done without accessing confidential patient information, it may at times be essential. At these times, you may access confidential patient information to engage in reflective practice if you:

• only access the minimum information required for reflection on that episode of care
• only access information where understanding the impact of your actions could directly influence the safety of future care you provide
• limit access to confidential patient information to recent episodes of care which are less than six months old, unless there is a good reason to extend the period
• follow your organisation’s local approval processes for all access to confidential patient information
• make a brief entry in the individual’s record explaining why access was necessary for your reflective practice
• respect any objection the patient or service user has made with regard to access to confidential patient information for reflective practice

The timeframe for accessing confidential patient information should allow you to work with your existing work commitments, such as clinical supervision cycles or planned team reflections. Note that while access to confidential patient information for the purposes of reflection should be time limited, the reflective process itself does not need to be time limited.

If you need to document information for the purposes of your own reflective practice you should ensure that any direct patient identifiers are removed. If you are using your organisation’s systems to document, you should follow all relevant organisational policies. If you use a personal electronic device to document your reflective process that includes information about a patient, you will need to follow the NHS England Bring your own device (BYOD) guidance.

Regulated health care professionals

Only regulated health care professionals who have a legitimate care relationship, past or present, with the person whose care they wish to reflect upon, should be allowed to access confidential patient information for reflective practice once a care episode has ended.

Non-regulated health care professionals

Some teams may include non-regulated staff see non-regulated health and care workers in the Information Governance (IG) professionals section of this guidance. These staff can participate in team reflective practice which requires access to confidential patient information, if:

• the team reflective practice is led by a regulated health care professional
• the decisions to access confidential patient information are made by a registered and regulated health care professional
• the non-regulated member of staff has a legitimate relationship, past or present, with the patient or service user for care, and was involved in the provision of the episode of care reflected on
• the non-regulated member of staff is up to date with their mandatory IG training
• their terms of employment include an explicit duty of confidentiality

At times you may need support from your clinical supervisor to effectively reflect on your practice. Where your supervisor has access to confidential patient information through your reflective practice, they should be a regulated professional and will usually be part of the care team involved in the episode you are reflecting on.

If your supervisor is based in a different clinical team, you must follow your organisation’s formal process when sharing information with them for reflective practice. If you are not sure about this process, you should check with your IG team.

You should respect any objection an individual has made to the use of their information for reflective practice. Also consider other reasons that could make the individual likely to object to you having access to confidential patient information to reflect on the care you provided. These could include the sensitivity of the records or the presence of unrelated information in the relevant section.

Reflective practice is about individual and team learning by those directly involved in an episode of care. As such, this guidance does not apply to broader organisational or system-wide learning.