On Health Records

Question 1

What’s in records?

Answer 1

• Notes of each patient contact
• Notes, letters and investigation reports in chronological order
• Summary of significant conditions
• List of long-term medication
• Key history and examination findings (including negative findings)
• X-rays, pathology, printouts, images etc

Question 2

What is SOAP?

Answer 2

o Subjective detail given by patient
o Objective findings of clinician including investigations
o Assessment of hypothesis formulated
o Plan of management including therapy and referral

Question 3

Why have them?

Answer 3

• As an aide mémoire for clinicians- have pts for many yrs
• To facilitate accurate and effective communication with other healthcare professionals
• To enable patients to participate in their own healthcare
• For clinical governance -therapeutic alliance and autonomy
• To provide a legal record of patient care
• Remember to read through as these can act as a method of poor comms

Question 4

Stats?

Answer 4

• ~40% of legal actions are indefensible because of the poor quality of the notes -MPS
• ~20% of cases are reported to be difficult to defend due to the poor quality of the notes-MDU

Question 5

How to refer?

Answer 5

• Cannot rely on patient to do your job in liaising with other health professionals
• Letters should allow other healthcare professionals to pick up care seamlessly
• Give idea of degree of urgency-eg. 2 week wait system
• If you order an investigation, the onus is on you to follow up that investigation
• In acute episodes advise as to when improvement should be seen and when to return
• In chronic illness and long-term therapy, review regularly and alert patient to important signs and symptoms

Question 6

Four fold duty?

Answer 6

o correct patient name & drug name
o no contraindications
o correct dose and directions are given
o provision for appropriate monitoring & follow up

Question 7

Norwell’s 10 commandments?

Answer 7

• Notes to be legible
• Date and Time of Consultation
• Signed by name and printed underneath signature-or if logged onto e-service
• Use only approved/unambiguous abbreviations
• Never alter or disguise entries
• No insulting or ‘humorous’ comments
• Check everything written in your name
• See and evaluate notes thoroughly before filing
• Do not dispose of notes
• Understand the law relating to access to records

Question 8

Who owns health reocrds?

Answer 8

PH service

Client if private

Question 9

Who can access?

Answer 9

• Patients (adults/children) [competent/incompetent] I: perhaps (and those with an LPA in England/Wales can too)
• Healthcare professionals- Patients can constrain clinical info between team [GMC para 10 “Confidentiality”] but unusual and unhelpful
• Healthcare students
• Researchers
• Relatives- no special rights; role of best interests –passive receivers of info
• Lawyers- consent necessary if not the pts lawyer.
• Police- complex (usually serious cases only)
• Social Services-not enough data is shared-children easier than parents with mental health illnesses
• Insurance companies or employers-consent only
• The media-consent only
• The dead patient!-GMC vs Law

Question 10

What is the Data Protecton Act 2018?

Answer 10

Implementation of GDPR

Question 11

Ethics?

Answer 11

• Genetic health information as a ‘shared account’-family history-third party info-care of families
• Use of ‘big data’ -leaks
• Health data post mortem -GMC vs law
• Health records over time and continuity of care - personal, info part of continuity, how health records change
• Health data as an element of personal autonomy includes data supporting it-needed to make decision about care
• Health data leaks