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Medical reports preserntation

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					Confidentiality
 The duties of a doctor registered with the General
  Medical Council
 Respect patients' right to confidentiality
 Patients have a right to expect that information about
  them will be held in confidence by their doctors.
  Confidentiality is central to trust between doctors and
  patients. Without assurances about confidentiality,
  patients may be reluctant to give doctors the
  information they need in order to provide good care.
  If you are asked to provide information about patients
  you must
Confidentiality
   inform patients about the disclosure, or check that they
    have already received information about it;
   anonymise data where unidentifiable data will serve the
    purpose;
   be satisfied that patients know about disclosures necessary
    to provide their care, or for local clinical audit of that care,
    that they can object to these disclosures but have not done
    so;
   seek patients‟ express consent to disclosure of information,
    where identifiable data is needed for any purpose other
    than the provision of care or for clinical audit – save in the
    exceptional circumstances described in this booklet;
   keep disclosures to the minimum necessary; and
   keep up to date with and observe the requirements of
    statute and common law, including data protection
    legislation
Consent
 Implied Consent
 Express Consent
   Valid Consent
   Informed Consent

   Competence
   Capacity
Consent
 Implied consent to disclosure
   Sharing information in the health care
    team or with others providing care
   Disclosing information for clinical audit
Consent
 Express consent for disclosure
   Disclosure of identifiable information for
    purposes such as research,
    epidemiology, financial audit or
    administration
   Third parties
Consent
 Disclosure in connection with judicial or
  other statutory proceedings & the Public
  Interest
   Disclosures required by law
   Disclosures to courts or in connection with
    litigation
   Disclosures to statutory regulatory bodies ( GMC
    FTP)
   Disclosures in the public interest ( Court‟s
    decide)
   Disclosures to protect the patient or others
Access to Medical Records
 Access to Health Records Act 1990
 From 1 March 2000-Data Protection Act 1998
 Formal applications for access must be in writing and
  accompanied by the appropriate fee
 Any patient
 Any person with parental responsibility
 Competent young people
 A person appointed by a court
 A competent patient may authorise a third party
Access to Medical Records
 Requests for access are made to the person
  in charge of keeping the records; the data
  controller
 Irrespective of who is the data controller,
  decisions about disclosure must be made
  by the „appropriate health professional‟
 Access must be given promptly and in any
  event within 40 days of receipt of the fee
  and request
Access to Medical Records
   The maximum fees which may be charged are prescribed by
    the Secretary of State and set out in Regulations
   If records are held totally on computer, a maximum of £10
    may be charged for providing access to and/or copies of the
    records
   No fee may be charged for allowing patients to read their
    records if all the information requested is held in manual
    form, no copy is requested, and at least some of the record
    was made in the 40 days prior to the request. If manual
    records have not been added to in the 40 days prior to a
    request to see the records, £10 may be charged
   If copies are requested, where at least part of the
    information requested is held manually, a reasonable fee of
    up to £50 may be charged for providing access and
    supplying copies
Access to Medical Records
 Certain information must not be released,
  and there is no obligation to inform patients
  if information is withheld on any of these
  grounds
 Third Parties
 Harm
 Confidentiality
 Legal privilege
 Court Proceedings
 Fertility treatment
 Children
Access to Medical Records
 Certain information must not be released,
  and there is no obligation to inform patients
  if information is withheld on any of these
  grounds
 Third Parties
 Harm
 Confidentiality
 Legal privilege
 Court Proceedings
 Fertility treatment
 Children
Access to Medical Records
 The Data Protection Act 1998 does not cover the
  records of deceased patients
 Statutory rights of access to these are contained
  within the Access to Health Records Act 1990
 Any person with a claim arising from the death of a
  patient has a right of access to information covered
  by the Act and directly relevant to that claim
 The Access to Health Records Act 1990 covers manual
  health records made since 1 November 1991.
 Access must also be given to information recorded
  before these dates if this is necessary to make any
  later part of the records intelligible.
 Exemptions Third Parties Serious Harm If deceased
  Patient requested non-disclosure
The Access to Medical Reports Act
1988 (the Act)
 The aim of the Act and the Order (the
  legislation) is simply to allow individuals to
  see medical reports written about them, for
  employment or insurance purposes, by a
  doctor whom they usually see in a "normal"
  doctor/patient capacity
 Before/After report & up to 6 months
 Disagree & Append this to report
 Withhold report by removing consent
The Access to Medical Reports Act
1988 (the Act)
Date stamp all requests for reports and date
correspondence sent to the applicant. (Remember the 21
day rule.)
Collate requests for access with requests for reports.
Inform the patient once the report is prepared.
Release the reports only after acting upon the patient's
expressed wishes in relation to seeing the report.
(Remember the 21 day rule.)
Do not release a report which has been "accessed" until
the patient indicates it may be released.
Amend errors of fact or judgement, or append the
patient's note of disagreement, as appropriate.
Keep copies of reports for a minimum of 6 months
The Access to Medical Reports Act
1988 (the Act)
 21 Day Rule
 Usually request this as part of
  process
 But can do anytime before report is
  sent (21 days apply from then)
 If Pt doesn‟t see then send day 21
 If Pt see‟s then need to give authority
  to send
 Reasonable charge for copy to see
The Access to Medical Reports Act
1988 (the Act)
 Withholding information
 Subject Access provisions of the Data
  Protection Act 1998
 Doctor has the right to withhold from the
  patient any information the release of
  which would cause serious harm to the
  mental or physical health of the patient.
 The patient must be informed of that
  restriction, and the rest of the report made
  available
 Lack Mental Capacity (Act-Nominate
  Individuals who act on behalf of)
IB113 DWP
   NHS GPs are under a statutory obligation to provide certain information to a Medical
    Officer when requested by the Department of Work and Pensions under their contracts
   80. - (1) The contractor shall, if it is satisfied that the patient consents -
    (a) supply in writing to a medical officer within such reasonable period as that officer,
    or an officer of the Department for Work and Pensions on his behalf and at his
    direction, may specify, such clinical information as the medical officer considers
    relevant about a patient to whom the contractor or a person acting on the contractor's
    behalf has issued or has refused to issue a medical certificate; and
    (b) answer any inquiries by a medical officer, or by an officer of the Department for
    Work and Pensions on his behalf and at his direction, about a prescription form or
    medical certificate issued by the contractor or on its behalf or about any statement
    which the contractor or a person acting on the contractor's behalf has made in a report.
    The regulations go on to clarify:
    (2) For the purpose of satisfying himself that the patient has consented as required by
    paragraph (1), the contractor may (unless it has reason to believe the patient does not
    consent) rely on an assurance in writing from the medical officer, or any officer of the
    Department for Work and Pensions, that he holds the patient's written consent
   MED3/4/5 Forms have an area for signed consent by patient
   Doctors should also be aware that they are only authorised by the current wording on
    the forms to disclose information that is needed for assessment by the DWP in that
    particular case and not extraneous details
Medical Reports
 DON‟T PANIC
 Consent
 21 Day Rule
 Give yourself time
 Read it carefully/what does the requestor
  want ? Factual or Factual & Opinion
 Check the patients notes carefully, both
  hand written and IT
 Share with patient if necessary
Medical Reports
 Who
   Name Qualifications Expertise
 Basis of the Report
   Written records
   & an examination
   Personal knowledge of
 Sources & Where
   ? Surgery
   Pre examination interview
   Clinical notes from
   Partially based on information from
   Clinical photographs
   Job description as enclosed by
Medical Reports
 Subjective/Objective Information
     During the interview XXX said
     I was informed by
     The information provided to me by
     On examination there were
     The clinical records show that
     The accident investigators report states
      that
Medical Reports
 Examination findings
   The records in my possession show that mrs xx
    blood pressure was
   On examination there were
   Mrs xx was able to walk from the car to the
    surgery without difficulty but
 Answer specific questions
   You have asked me to comment on
 Conclusions & Opinions
   Mrs xx injuries are/are not consistent with
   The mechanism of injury is
Medical Reports
 Prognosis
   It is likely that
   In my opinion she will not recover from
   Mrs xx will be unable to return to work
 Future treatment/recommendations
   X rays
   Further Rx etc
Medical Reports
 Phrases that are useful
   My report is provisional to the extent
    that
   I would recommend that
   The question referred to is outside my
    area of expertises
   Avoid “will never work” or “will make a
    full recovery”
   Use “is unlikely to “ or “will probably”

				
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posted:12/11/2011
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