Medical Confidentiality

Question 1

role of medical records in clinical practice

Answer 1

administration and management
legal compliance
clinical audit
clinical research
clinical evidence

Question 2

maintenance of medical records: appropriate clinical content

Answer 2

x-rays and clinical imaging
photos
audio and video recordings
patient monitoring printouts
patient consent forms

Question 3

maintenance of medical records: good record keeping

Answer 3

differential diagnosis
clinical investigations
clinical referrals
clinical information
patient consent process
medical treatment plan
clinical follow up
patient care plan

Question 4

maintenance of medical records: essential content

Answer 4

subjective
objective
assessment
problem list and plan

Question 5

subjective

Answer 5

medical information from the patient

Question 6

objective

Answer 6

medical examination of the patient

Question 7

assessment

Answer 7

medical diagnosis and prognosis

Question 8

problem list and plan

Answer 8

medical management and care plan

Question 9

professional maintenance of medical records

Answer 9

clear
objective
contemporaneous
attributable
original

Question 10

medical record correction procedure

Answer 10

signature, name (capitals), counter signature
sate and time of alterations/ deletions
reason for alterations/deletions

Question 11

non-use of clinical abbreviations

Answer 11

patient transfer
patient discharge
external consultant referral letters
consent forms
death certificates
incident report forms
trust communications

Question 12

clinical risk management issues

Answer 12

non-record of:
-negative clinical findings
-details of consultation
-drug allergies/adverse clinical reacitons
-clinical investigation and test results

Question 13

risk management issues

Answer 13

non-correction of illegible entries
non-referral to medical records in patient consultation
non-removal of derogatory remarks or failure tot double check patient subject matter

Question 14

medical records and clinical disclosure procedure

Answer 14

anonymisation or codification
patient informed consent
minimisation
legal compliance

Question 15

medical records and inappropriate disclosures

Answer 15

non-discussion in public place/social media
non-sharing of computer passwords and raise patient safety and information governance concerns

Question 16

disclosure of patient clinical information: administrative and professional considerations

Answer 16

nature of clinical information
proposed use of clinical information
prospective recipients of clinical information
medical confidentiality and security arrangements and potential for distress or harm

Question 17

disclosure of patient clinical information: clinical procedure for absence of patient mental capacity

Answer 17

advance healthcare planning review
patient legal power of attorney consultation or family/friends/carers consultation

Question 18

disclosure of clinical information of a deceased patient: administrative legal or clinical purposes

Answer 18

coroners court hearing
death certificates
public health surveillance
parental enquiries (neo-natal/ peadiatric death) or formal request of deceased patient spouse, next of kin or legal representative

Question 19

legal definition of confidential information, Lea on medical confidentiality

Answer 19

A Medical Practitioner must use the Patient’s Clinical Information
in compliance with the General Medical Council’s, GMC’s, Guide on
Professionalism, “Good Medical Practice”, and the Legal Doctrine of
Medical Confidentiality

Question 20

legal categories of confidential information

Answer 20

personal
government
commercial
medical

Question 21

action for breach of confidence: patient clinical information

Answer 21

confidential in nature
exchanged in clinical consultation
disclosed in unauthorised manner

Question 22

lion laboratories v evans

Answer 22

(Protecting General Public from Unlawful Arrest and Prosecution)

Question 23

X v Y & Others

Answer 23

(Protecting Confidentiality of Medical Records outweighs PublicInterest in Freedom of the Press)

Question 24

Tarasoff v Regents of University of California

Answer 24

(Protecting General Public outweighs Protective Clinical Privilege)

Question 25

Lipari v Spears

Answer 25

(General Legal Duty to Predict Danger & Protect Society)

Question 26

Brady v Hopper

Answer 26

Legal Duty Limited to Specific Threats to Specified Individuals)

Question 27

W v Egdell

Answer 27

(Legal Duty to Protect General Public from Serious Harm or Injury)

Question 28

Palmer v Tees Health Authority

Answer 28

(Legal Duty Limited to Special Relationship with Identifiable Victim)

Question 29

W v Egdell

Answer 29

(Common Law Duty of Medical Confidentiality

Question 30

McInerney v McDonald

Answer 30

(Fidiuciary Relationship & Mutual Trust)

Question 31

McInerney v McDonald

Answer 31

(Medical Information Personal Property of Patient)

Question 32

R v Mid Glamorgan FHSA & South Glamorgan Health Authority

Answer 32

(Medical Interpretation & Medical Diagnosis Professional Property of Medical Practitioner)

Question 33

data controller

Answer 33

medical practitioner

Question 34

data subject

Answer 34

patient

Question 35

personal data

Answer 35

patient clinical information

Question 36

medical record

Answer 36

physical and mental health factual and professional opinion electronic and manual form

Question 37

clinical and personal information in medical records

Answer 37

clinical consultation notes referral and discharge letters clinical tests results video and audio recordings clinical samples clinical reports for third parties

Question 38

data protection principles

Answer 38

be processed lawfully, fairly and transparently be processed for specified, explicit and legitimate purposes be adequate, relevant and limited to necessary purposes be accurate and up to date not be stored for longer than necessary be stored safely and securely

Question 39

conditions for data processing

Answer 39

data subject consent performance of a contract legal obligation of the data controller vital interests of the data subject performance of public interest task or exercise of official authority legitimate interests of the data controller or third part y

Question 40

administrative and professional maintenance of medical records

Answer 40

clear, accurate,factual, legible and comtemporaneously recorded clinical findings, treatment decisions and patient clinical information no personal views or derogatory remarks facilitate patient access to medical records no amendment/change unless correct or remove misleading or inaccurate clinical information no amendment/change at patient/familt request

Question 41

patient informed consent

Answer 41

voluntary specific and informed unambiguous right to refuse/withdraw

Question 42

subject access request

Answer 42

mental capacity, mature minors, young people, next of kin and solicitors made electronically, in writing and verbally identity verification by reasonable means in 28 days patient consultation on disclosure refusal if manifestly unfounded or excessive provided in electronic or manual format and fees payable explanation of clinical term

Question 43

grounds for refusal of subject access request

Answer 43

prevent physical/mental harm to patient or third party protect medical confidentiality of third part and legal professional privilege restricted by law or court order

Question 44

subject access request and third parties

Answer 44

parents legal power of attorney and legal state of deceased police insurers