You are on page 1of 10



Staff should respect the individual patients cultural, religious and ethnic
beliefs and make arrangements as required in relation to diet, worship
and care of the dying and be documented in care records
4.6.3 The nurse ensures that specific cultural, religious and ethnic beliefs and needs are
documented in the nursing/midwifery records. Staff respect the individual patients
cultural, religious and ethnic beliefs and make arrangements as required in relation
to diet, worship and care of the dying.
4.9 Healthcare users should be given access to a choice of appropriate foods, e.g.
ethnic/religious choices, vegetarian/vegan and age appropriate. Support
should also be provided when assessed as appropriate to ensure that food
can be consumed
Do you know the cultural background of your patient?
Do you know who is the family spokesperson? Do
you know the religious or faith tradition of your
patient? What are their dietary requirements?
Try to ascertain any belief or cultural issues
relevant to the intended treatment plan. Use
interpreters to explain and involve the carers.

Talk to your patients or their carers about any

specific cultural, religious or faith tradition

Consult available experts: your local Interpreter

Service, Multicultrual Health Service, Aboriginal
Liaison Officers and Accredited Hospital Chaplains
are all there to provide information and advice on
how to respect culture and faith traditions

Let patients and carers know about interpreters,

chaplains, prayer rooms etc available in the

A person who requires end of life care either within the hospital or home
setting will be cared for sensitively and empathetically. Death will be
handled with dignity and compassion and in accordance with cultural
and religious beliefs of the individual person and their family.

Service users have a right to:

Be cared for in a single sex environment within in-patient settings
To be cared for within their own home where appropriate to do so
3.2 Protection of privacy
3.2.1 The health facility takes measures to protect patient privacy.
Intent of 3.2.1
The health facility ensures that the patient's needs for privacy are respected, especially when
the patient is providing personal information and undergoing clinical examination. Patients

may desire privacy from other personnel, other patients, and even from family members.
Medical and other health information, when documented and collected in a patient record or
other form, is important for understanding the patient, his or her needs, and for providing care
and health facilities over time. The health facility respects such information as confidential,
and has implemented policies and procedures that protect such information from loss or
misuse. The personnel respect the confidentiality of patient information by not posting
information on the patient's door or at the nursing station and by not holding patient-related
discussions in public places. The misuse of patient information can result in the patient's loss
of dignity, employment, and damage to personal or family relationships. Such information can
SafeCare 2011 Patient rights and Access to care Clinic/health centre standards for RRS

be misused by the personnel of the health facility, family members or others not authorised to
have access to the information.

3.2.1 Criteria The patient's need for privacy is protected during all examinations,
procedures and treatments. The patient's need for privacy is protected when providing personal
information. The patient's right to privacy is protected for all forms of counselling. Policies and procedures to prevent the loss or misuse of patient
information are implemented. The policy includes the right to confidentiality of patient records.

The need for auditory privacy is considered and staff ensure that private or sensitive
conversations with patients wherever possible cannot be overheard.
In addition, staff ensures that sensitive or inappropriate discussions about patients
cannot be overheard, this includes in public areas such as in lifts and corridors
where conversations may be overheard.
If Designated Quiet Rooms are available, these are used as much as possible for
breaking bad news and sensitive conversations.
4.2.3 Curtains (window, bed, cubicle and shower) and screens are fit for purpose. The
ward/ dept manager is responsible for ensuring these are maintained in good
condition and regularly cleaned in patient areas.
4.2.4 Curtains are used appropriately to provide patients with privacy when they wish,
such as at night or during recovery from sedation unless this interferes with patient
safety by compromising patient observation and monitoring.
4.2.5 Staff request permission before entering a curtained area or closed door.
4.2.6 Patients are suitably covered or dressed at all times, in their own clothes or night
clothes if possible. Particular care should be given to the dignity of confused
patients, ensuring the use of appropriate and safe footwear, that underwear, pyjama
trousers and night clothes are secured properly and that patients own clothes are
encouraged to be worn whenever possible. Hospital gowns should only be worn
when going to theatre or for investigations and they will be secured to prevent
inappropriate exposure.
4.2.7 Commodes or bed pans are used only if the patient cannot be assisted to the toilet.
If a commode or bedpan needs to be used consideration should be given to
proactively offering these before mealtimes.
4.2.8 All toilet facilities, in adult areas will be either male or female.
4.2.9 Urinals must be put in a holder on the bed and not left on the patients bed table.

4.2.10 The nurse is responsible for ensuring the privacy of dependent patients using the
toilet or bathroom facilities. All patients are offered the opportunity to wash their
hands after using the toilet, commode or bed pan and before mealtimes.
4.2.11 If patients are requiring assistance in being fed, where necessary curtains should be
drawn to maintain the patients dignity throughout mealtimes.
4.2.12 Bathrooms must be available for patient use and not used for storage.
4.2.13 All ward round teams limit the number of staff present during physical examinations
to a minimum. Patients should be given enough notice to prepare themselves for a
ward round wherever possible.
4.2.14 Patient permission should be obtained before students (of any discipline) are
involved in patient care and ward rounds.
4.2.15 Any plans for structural changes, temporary ward use or new builds will include
plans to maintain privacy and dignity and will adhere to same sex accommodation
4.6.12 Patients who are being discharged should wherever possible wear their own
clothing & footwear.
4.4 NHS Highland staff should inform all healthcare users about the Mobile Phone
Policy relevant to the area of practice. In particular the use of photographing
and making video recordings when using mobile phones in hospital.


All staff to wear a visible identification badge and to introduce themselves to

All staff and visitors will be acknowledged upon entering the clinical area and staff
will identify themselves (title and surname) and venue when they are answering the
telephone, in line with good customer service skills.


Patients have a right to expect that:
Patient information is shared to enable care, with their consent.
Best Practice:
Only sharing information that a service user discloses, with staff who are
directly involved in their care and with the service users verbal consent.
Staff asking for personal and demographic details ensure they cannot be
Obtaining service user consent before disclosing information to family,

carers and friends.

Being aware of and alert to anyone who may overhear staff
conversations. It is not acceptable to discuss clinical information in
public areas even if a service users name is not used.
Ensuring written service user information which contain confidential
details are disposed of correctly and are not left in public places.
Precautions are taken to prevent information being shared
inappropriately, e.g. computer screens being viewed and white boards
being read.
4.6.8 White boards displayed in open clinical areas must contain the patients name only,
no diagnosis will be displayed or clinical status that is patient identifiable to comply
with Caldicott and PEAT guidelines.
4.6.9 Records at the end of the patients bed must not be read by visitors and other

The primary purpose of the medical record is to document the course of a patients
and treatment during all periods of the patients care. The medical record is extremely
important as a permanent account of the patient care provided. It serves as a means of
communication between physician and other health care professionals. As such, it is
a tool for planning and evaluating patient care.
In order for the medical record to be a useful instrument in patient care, it must contain
accurate, detailed, personal information relating to each patients medical, surgical,
psychiatric, social, and family history.
Patients have the right to expect their medical records are treated as confidential, and
North Idaho Eye Institute personnel have an obligation to safeguard Protected Health
Information against unauthorized disclosure. North Idaho Eye Institute is HIPAA
compliant and all employees are expected to follow HIPAA guidelines, policies and
Patient privacy is maintained orally, electronically, and on paper.
Employees shall never discuss a patients medical condition with any non-employee
of the practice, friends, or family members.
Protected Health Information is released/shared on a need to know bases.
Employees do not discuss patients in public or within the vicinity of other patients.
Discussion of Protected Health Information among co-workers can only be for
treatment, operation, or payment on a need to know bases and only to personnel
involved with direct and identifiable need to receive PHI.
Patient schedules are covered from public view. Patient lists, charts, and confidential
papers are kept out of patient view. Computer screens are angled to prevent patient
view and are promptly placed on neutral after finishing current task.
Papers that contain PHI and are ready for disposal will be placed in a container
stored for shredding and not disposed in the regular trash or recycling.
Patients have a right to inspect, copy, and amend their medical records; receive an

accounting of disclosure of PHI; and file a complaint.

If the office received a call in regards to an appointment time for a patient, the steps that
should be taken are the following:
If the patient makes the call and you are unsure of their identity, ask for
identifying factor such as year of birth or last four digits of their Social Security
If the caller is not the patient check who is calling and what the relationship of
this person is to the patient.
PATIENT CONFIDENTIALITY Policy & Procedure.pages
If the caller claims to be the source of transportation,

guardian, etc., check to see

if patient has given permission to release information to the caller. If permission
has been granted, and you are not sure of the identity of the caller ask for an
identifying factor such as year of birth or last four digits of the patients Social
Security Number. If you are reasonable sure of the callers identity, you do not
need to secure evidence.
If permission has not been granted to the caller, take the name and phone number
and attempt to problem solve. Attempt to contact the patient to obtain permission
to give the original caller the appointment information.
The business office will use the preceding steps for calls concerning billing questions.
If you give out PHI to someone other than to those authorized by the patient, you will
need to document who you gave the information to and the reason that you gave it. Use
the Accounting of Disclosures of Protected Health Information form and give to the
Privacy Officer.
PATIENT CONFIDENTIALITY Policy & Procedure.pages

All healthcare users information is confidential. Specifically all information

about diagnosis and care will, in the first instance, be discussed with the
healthcare user or their legal guardian as privately as possible. This
information will only be shared with others following the agreement of the
healthcare user. However, while it is important that a healthcare users right to
confidentiality is respected, it is also important to ensure that this does not
result in a failure to provide healthcare users with the appropriate care

3.3.1 The health facility supports and protects the right of patients and
families to participate in the patient care process.
Intent of 3.3.1
Every patient is offered the information and education he or she requires. Health facilities
may choose to appoint education co-ordinators, education committees or they may work with
all personnel to provide education in a co-ordinated manner.

3.3.1 Criteria The health facility plans education consistent with its health facilities
and patient population. There is an appropriate structure or mechanism for education
throughout the health facility. Patient and family education promotes the concept of taking
responsibility for one's own health care. The patient and his/her family are taught in a language and format that
they can understand. The health centre identifies and establishes relationships with
community resources, which support continuing health promotion and
disease prevention education. There is a uniform process for recording patient education information

Staff explains explains medical terminology and procedures in a way that patients
and their carers can understand. Patients are encouraged to ask questions and are
made aware of whom to address these to.

3.8 Information for patients about the services offered

3.8.1 The health facility has a process for informing patients and their
families about its services and how to access those services.
Intent of 3.8.1
To improve access to its services, the health facility provides information to the community on
its services and hours of operation and how to obtain care.
During the entry process, patients and their families receive sufficient information to make
informed decisions about seeking care. Information is provided on proposed care, the
expected results, and any expected cost to the patient or family for that care, when this is not
paid for by a public or private source. Patients and families need complete information on the
care and services offered by the health facility and on how to access those services.
Providing this information is essential to building open and trusting communication between
patients, families and the health facility. This information helps to match the patient's
expectations to the ability of the health facility to meet those expectations. Information on
alternative sources of care and services is provided, when the needed care is beyond the
health facility's mission and capabilities.
For patients and families to participate in care decisions, they need basic information
regarding the medical conditions found during assessment and on the proposed care and
treatment. Patients and families understand when they will be given this information and who
is responsible for telling them. Patients and families understand the kinds of decisions that
must be made about care and how to participate in those decisions. In addition, patients and
families need to understand the health facility's process for obtaining consent and which care
processes, tests, procedures and treatments require their consent.
While some patients may not wish to personally participate in the decisions regarding their
care, they are, nevertheless, given the opportunity, and can choose to participate through a
family member, friend or a surrogate decision-maker.

3.8.1 Criteria Patients are given information about the care and services provided by
the health facility.
SafeCare 2011 Patient rights and Access to care Clinic/health centre standards for RRS Information is provided in a way and in a language that is understood

by those making the care decisions. Information on services, hours of operation, and processes for
obtaining care is provided to agencies and referral sources in the
community, and to the population served.

Patients are advised of the name of the person in charge of the ward and
information on how to contact a Matron is clearly displayed
All patients who do not have English as their first language are offered an

interpreter. This can be arranged through the FTs Interpreting Services on 0161
291 5207. Staff should contact the Duty Manager for an out of hours interpreting

Service users should have the opportunity to discuss with staff if they
have any objections to health professionals (not directly related to their
care) being present in ward rounds, out-patient appointments etc. These
wishes should be adhered to as required.
3.4 Right to treatment and to refuse treatment
3.4.1 The health facility respects the rights of patients and families to
receive treatment and to refuse or discontinue treatment.
SafeCare 2011 Patient rights and Access to care Clinic/health centre standards for RRS

Intent of 3.4.1
Patients, or those making decisions on their behalf, may decide not to proceed with the
planned care or treatment or to continue care or treatment after it has been initiated. The
health facility informs patients and families about their right to make these decisions, about
the potential outcomes that could result from these decisions, and about their responsibilities
related to such decisions. Patients and families are given information on any care and
treatment alternatives. The personnel are informed of their responsibility to implement and
respect the choices of patients.

3.4.1 Criteria Patients are informed about their condition and the proposed treatment. Patients and families are informed about their rights to refuse or
discontinue treatment. Patients are informed about the consequences of such decisions.



Panduan nyeri


3.5 Right to voice complaints

3.5.1 The health facility informs patients and their families about the
processes it has instituted to receive and act on complaints,
conflicts and differences of opinion about patient care, and the
patient's right to participate in those processes.
Intent of 3.5.1
Patients have a right to voice complaints about their care, and to have those complaints
reviewed and, where possible, resolved. Also, decisions regarding care sometimes present
questions, conflicts or other dilemmas for the health facility and the patient, family or other
decision-makers. These dilemmas may arise around issues of access, treatment or
discharge. The health facility has established processes for seeking resolutions to such
dilemmas and complaints. The health facility identifies in policies and procedures those who
need to be involved in the processes and how the patient and family participate.

3.5.1 Criteria There is a mechanism to allow complaints to be heard and acted upon. Patients are aware of their right to voice complaints and the processes
by which to do so. Complaints are recorded, evaluated and analysed


NHS Highland staff should ensure that healthcare users feel valued and do
not experience any negative or offensive behaviour. NSH Highland should
ensure that they are positively promoting equality and diversity.
NHS Highland staff are personally accountable for ensuring that they promote
and protect healthcare users well-being, Staff should also recognise and
prevent any barriers to access and support because of stereotyping, or stigma
associated with age, ethnicity, disability, faith, sexual orientation and gender.
The preferred name which the healthcare user wishes to be known should be
determined and recorded.
NHS Highland staff should be easily identified by healthcare users by the use
of nationally agreed uniform policies and NHS Highland name badges.
NHS Highland staff should be aware of the possible negative effect of nonverbal
communication/body language and gestures.
Healthcare users should never be left without clothing or a covering when bed
bathing to maintain their privacy, dignity and respect.
NHS Highland staff should encourage healthcare users, who are able to do
so, to bath, shower and toilet themselves, with minimal supervision, unless a
risk has been identified.
NHS Highland staff should be aware of healthcare users sensitivities with
regard to personal contact/touch and personal boundaries. In particular, these
issues might arise as a result of gender, culture and ethnicity
Requests by healthcare users and carers, to be treated by a member of staff
of a specific gender or religion will be considered, according to availability of
staff and/or resources.
6.1 NHS Highland staff should introduce themselves on initial contact with
healthcare users and/or carers, stating their names and roles.
6.2 All communication between NHS Highland staff and healthcare users should
be in a manner that displays respect for their individuality.
6.3 The clarity of any written information or leaflets should follow guidelines set by
the Policy on Management of Policies and Procedures.
6.4 NHS Highland staff should ensure that they are aware of the communication
needs of healthcare users and are able to ensure that any communication is
understood by the healthcare user.

6.5 Clear explanation should be given to the healthcare users by the appropriate
staff member, before any action or procedure is commenced.
6.6 NHS Highland staff should restrict conversations involving patient information,
to areas where others cannot hear.
6.7 NHS Highland staff should also restrict conversations involving their own
personal information to non-clinical areas.
6.8 Any written information regarding healthcare users (e.g. patient notes) should
be treated with privacy and respect, with high regard to confidentiality.
6.9 NHS Highland staff should clearly identify themselves and/or make their
presence known before entering screened areas or rooms.
3.9 Responsibility of All Staff
All clinical staff, including therapy and medical staff are responsible for ensuring the
privacy and dignity of individual patients and clients is maintained, and for raising
concerns. All non clinical staff must be aware of the importance of privacy and
dignity and ensure this is paramount in any patient contact.

Individual Responsibility
All employees will, at all times, behave in a way that promotes openness and displays
unconditional positive regard, giving due consideration to the manner in which they treat
others does not inadvertently discriminate against any groups based on their race, disability,
gender, age, sexual orientation, religion and belief.
Trust employees will promote the vision and values of the organisation through
professional, personal appearance, appropriate communication and non-discriminatory
Promote the dignity of all people.
Participate in any related training or service development initiatives identified by their
Adhere to the principles set out in this policy
To comply with the Professional Code of Practice of their governing bodies e.g. Royal
College of Psychiatrists, Nursing and Midwifery Council.
To uphold the duty of care and practice within the legislative framework. E.g. Human Rights
Act (1998), Mental Capacity Act (2005).
To disclose any non-compliance with the policy to their line manager
To utilise the incident reporting system should there be any breach to the principles
highlighted within this policy


To promote patient rights in a health facility, one starts by defining those rights,
followed by educating patients and the personnel about those rights. Patients are
informed of their rights and how to act on them. The personnel are taught to
understand and respect patients' beliefs and values and to provide considerate and
respectful care, thus protecting the patients' dignity.

Admission to a health facility can be a frightening and confusing experience for patients,
making it difficult for them to understand and act on their rights. Thus, the health facility
prepares a written statement of patient and family rights, and this is given to patients when
they enter the health facility for care, and is available throughout their stay

Information on how to raise a concern or a formal complaint will be available in

every clinical area.
Information on the Patient Experience Service is clearly displayed.