Interproffesional Communication

Question 1

Why keep medical record

Answer 1

• Good medical records are needed for
  
  • Good medical practice
  • Healthcare is a multidisciplinary team process
  • To ensure that patients are treated efficiently and effectively, it is important that you, and other health professionals, have easy access to high quality patients record

Question 2

General medical council

Answer 2

• Clinical records should include
  
  • Relevant clinical findings
  • the decisions made and actions agreed, and who is making the decisions and agreeing with the actions
  • the information was given to patients
  • any drugs prescribed or other investigation or treatment
  • Who is making the record and when
• Make records at the same time as the events you are recording or as soon as possible afterwards
• Keep colleagues well informed when sharing the care of patients

Question 3

NHS UK

Answer 3

• Health records play an important role in modern healthcare
• They have 2 main functions, which are described as either primary or secondary
  
  • Primary- to record important clinical information
  • Secondary-To improve public health and the services provided by the NHS
    
    • Performance review of the hospital and the services provided by the NHS
    • Epidemiology
    • Clinical research

Question 4

Types of health record

Answer 4

• Health records take many form and can be on paper or electronic
• Different types of health record include
  
  • Consultation notes (GP or Hospital specialists)
  • Hospital admission records
  • Hospital discharge records
  • Test results (including photographs, blood tests, X-rays and image slides

Question 5

Confidentiality

Answer 5

• There are strict laws and regulations to endure that your (the patients) health records are kept confidential and can only be accessed by health professionals directly involved in your care
• You cannot interrogate patient notes without authorisation or reason of direct patient care
• The human right act 1998 states that everyone has the right to have their private life respected
  
  • This includes the right to keep your health records confidential

Question 6

Legality

Answer 6

• Key legislation documents
  
  • Data Protection Act of 1998
  • Human rights act 1998
• Data protection act- 1998
  
  • Organisation (such as the NHS) must ensure that any personal information it gathers in the course of its work is only used for the stated purpose of gathering information (which in this case would be to ensure that you receive a good standard of healthcare) and kept secure
  • It is a criminal offence to breach the data protection act and doing so can result in imprisonment

Question 7

The data protection act

8 core principles

Answer 7

• Processed fairly and lawfully
• Obtained & used only for specified and lawful purposes
• Adequate, relevant and not excessive
• Accurate, and where necessary, kept up to date
• Kept for no longer than necessary
• Processed in accordance with the individual’s rights
• Kept secure
• Transferred only to countries that offer adequate data protection

Question 8

Caldicott Guardians

Answer 8

• A Caldicott guardian is a senior person responsible for protecting the confidentiality of patient and service-user information and enabling appropriate information-sharing
• The guarding plays a key role in ensuring that the NHS< Councils with social services responsibilities and partner organisations satisfy the highest practicable standards for handling patient identifiable information
• In an NHS trust, this would usually be aborad-level clinician; for a primary care trust it might be the medical director or director of public health
• If you require to move nots OFF NHS trusts property or have reason for a special access request, you must submit a request to the caldicott guardian

Question 9

Retention of notes

Answer 9

• For the record, managing records in NHS trusts `and health authorities
• Similar guidance applies in other parts of the UK
• The department of health replaced this guidance with a new record management: NHS code of practice

Question 10

Minimum retention period

Answer 10

• Child health record- retain until the patients 25th birthday or 26th if young person was 17 at conclusion of treatment or 8 years after death
• Maternity records- 25 years after the birth of the last child
• Mental disorder records- 20 years after the date of the last contact; or 10 years after patients death if sooner
• Oncology- 30 years
• Donor records- 30 years after transplant

Question 11

Note format

Answer 11

• When planning medical notes remember
  
  • Medical notes should not allow another medical professional to reconstruct your consultations with the patient
  • It is likely that the patient, their relatives or representative will read the notes in the future
  • You may be required to give an explanation under the data protection act if the information contained in the records is not intelligible

Question 12

Electronic records

Answer 12

• NHS summary care records (SCR)
• An SCR is an electronic record that is stored at a central location
• The record will contain important health information such as
  
  • Prescription meds, allergies and ADR’s
• You can now choose to include more information in your SCR
  
  • Significant medical history (past and present
  • Info about management of long term conditions, immunisation
  • Patient preference such as the end of life care
• The electronic records allow NHS professionals to have reliable and rapid access, 24 hours a day, to the relevant personal information necessary to support their care
• Access to patients is now live

Question 13

Paper records

Answer 13

• Medical notes
  
  • Current episode section
  • Outpatient clinic notes
  • Discharge summary
  • Correspondence to GP/other professionals
• Prescription charts
  
  • Drug chart
  • Fluid and infusion chart
  • Feed charts
• Nursing records
  
  • Observation charts

Question 14

Abbreviations

Answer 14

• Using abbreviations saves time, but can lead to problems
• Abbreviation should be unambiguoud and universal
  
  • TOF- Tetralogy of fallot or tracheo-Oesophageal fistula
  • MS- Multiple Sclerosis or Mitral Stenosis
  • PID- Pelvic Inflammatory Disease or Prolapsed Intervertebral Disc
• Certain abbreviations are unacceptable, such as coded expressions of sarcasm, or humorous abbreviations to describe a patients condition
• Remeber to be prefessional- Anything you write could be seen by the patient, family, courts or public

Question 15

Official Do not use List

Answer 15

• The joint commission
• Board of commissioners approved a national patient safety goal requiring accredited organisations to develop and implement a list of Do not use abbreviations
• The joint Commission Do not use list
• NPSG (2010) integrated into the information management standards

Question 16

Quality of notes

Answer 16

• Clear- identify the patient clearly, write legibly in black ink and sign each entry with a date and time
• Objective- opinions should be based on the FACTS given
• Contemporary- Write notes up straight after an event
• First-hand- record the name and position of source info e.g. relative, friend, translator
• Tamper-proof- write in pen and not pencil. Computer systems should record the date and author of any notes and track any amendments
• Original- Medical records should not be altered, or amended without suitable annotations (single line through and date initials given)

Question 17

What to include

Answer 17

• History- relevant to the condition
• Examination- any important findings
• Diagnosis- it should be clear from your notes how you arrived at this conclusion and details of any further investigations you have arranged
• Information- what you have told the patient, including any details of the risks and benefits of treatments
• Consent- details of any consent the patient has given, together with the background discussions
• Treatment- details the type and dosage of drugs, the total amount prescribed and any other treatment you have organised
• Follow up- include the arrangements for following up tests, future appointments and any referrals made

Question 18

Problem-based notes

SOAP

Answer 18

• Subjective- Any information you receive from the patient (history of present illness, PMH)
• Objective- any data, whether in the form of a physical finding during your exam or lab results
• Assessment- diagnoses derived from the history of objective data
• Plan- what you intend to do about the diagnoses from your assessment

Question 19

Communication and human factors

Answer 19

Question 20

Human factors

Answer 20

• Human factors encompass al those factors that can influence people and their behaviour
• In a work context, human factors are the environmental, organisational and job factors and individual characteristics which influence behaviour at work
• How good are you at the non-technical skills

Question 21

Lessons from human factor

Answer 21

• Understand which system factors threaten patient safety
• Improve the safety culture of teams
• Enhance teamwork and improve communication
• Improve the design of healthcare systems
• Identify and predict ‘what could go wrong’
• Appreciate how to lessen the likelihood of harm

Question 22

Communication tools SBAR

Answer 22

• Situation
• Background
• Assessment
• Recommendation

Question 23

Situation

Answer 23

• Identify yourself the site/unit you are calling from
• Identify the patient by name and the reason for your report
• Describe your concern
• Firstly, describe the specific situation about which you are calling including the patient’s name, patient location and vital signs. An example of a script
  
  • This is Lou, a pharmacist calling from the PICU. I have just seen James Lockwood who has been given IV salbutamol and there has been an overdosing error. He has a severe tachycardia

Question 24

SBAR

Background

Answer 24

• Give the patient’s reason for admission
• Explain the significant medical history
• You then inform the consultant of the patient’s background: Admitting diagnosis, date of admission, prior procedure, correct medication, allergies, pertinent laboratory results from and other relevant diagnostic results
• For this, you need to have collected information from the patients chart, flow sheets and progress notes for examples
  
  • James is an otherwise fit and well 5 year old. Hew was brought in this morning with acute life-threatening asthma

Question 25

SBAR

Assessment

Answer 25

• Vital signs
• Contraction pattern
• Clinical impressions, concerns
• You need to think critically when informing the doctor of your assessment of the situation
• This means you have considered what might be the underlying reason for your patient’s condition
• Not only have you reviewed your findings from your assessment, but you have also consolidated these with other objective indicators, such as laboratory results

Question 26

SBAR

Recommendations

Answer 26

• Explain what you need- be specific about request and time frame
• Make suggestions
• Clarify expectations
• Finally what is your recommendations- that is what you would like to happen by the end of the conversation with the physician
  
  • Any order that is given on the phone needs to be repeated back to ensure accuracy
  • I advise the nurse to stop the infusion. I would like you to come and see him immediately

Question 27

Recommended uses and settings for SBAR

Answer 27

Question 28

Social Media

Answer 28

Question 29

Summary

Answer 29

• Medical Notes
  
  • Clinical notes in UK hospital
  • Structure of medical not keeping
  • Abbreviations in medical use
  • Guidelines for making an entry in the medical notes
  • Confidentiality of notes
  • Legal status of notes
• Communication
  
  • Importance of human factors
  • SBAR communication tools
  • Social networking- risks and guidance