priv + confidentiality + records + consent Flashcards
(15 cards)
decision making involves
- law
- ethics
- morals
- values
the Charter of Human Rights is produced by
aus commission on safety and quality in HC
ACSQHC
list two types of relevant legislation for privary
commonwealth act
- privact act 1988
[regulates how person info is handled]
- amended by Privacy Amendment (Enhancing Privacy Protection) Act 2012
- contains 13 aus privacy principles [APPs]
NSW Act
- Health Records and Information Privacy Act 2002
the regulator for privacy related matters
office of aus information commissioner [OAIC]
- conduct investigations, reviews decisions, handles complaints, provides guidance + advice
- independent national body
list reqs for dentist under the APP Privacy Act 1988
clear + up to date privacy policy which details how the practic ewill manage personal info + steps for pts to access that info
- policy must be available on request + if there is a website, it should be on it
distinguish primary and secondary uses of personal info
primary
specific purpose for which the entity collect the infomation eg to provide dental advice + tx
secondary
if info was then to be used for marketing, research, teaching capacity
describe breaches of APPs and what happens
breach = interference w pt privacy
office of aus information commissioner [OAIC]
- will investigate
- has enforcement powers
- emphasis of conciliation of complaints rather than punishment
describe what is entailed in the AHPRA code of conduct 3.3 confidentiality and privacy section
a. respect C/P by seeking informed consent before disclosing info/docs
b. provide surroundings to enable private conversations eg closing the door
c. never access records when not involved in care/ authorised to do so
d. ensure staff are aware of C/P principles and do not discuss pts out of professional context [eg ensuring fdesk screens are not revealing personal info, phone calls are]
e. be aware of req of P/C legislation
f. complex issues relating to genetic info
g. do not share personal image w/o written + informed consent
h. pt right to access info = help them, facilitate transfer
describe what is entailed in the AHPRA code of conduct 4.8 personal relationships
good practice incl recognising potential conflicts, risks and complexities of providing care to someone in a personal relationship
- lack of objectivity = anxiousness and overconservatism
- possible continuity of care
- pt reluctance to reveal medical info
- payment
(resulting interpersonal conflicts from)
- poor/adverse outcomes
- failure to meet pt expectations
important to note that the boave interactions are possibilities of all pts, however the additional complexity of personal relationships should be considered and whether related complicated could be mitigated
list the elements of good record keeping
- accurate, up to date, factual, objective, eligible records which report relevant details of hx, clin findings, info given to pt, medis
- sufficient to facilitate continuity of care
- make records at time of event / ASAP afterward
- prompty facilitate transfer incl disposal
list what is included in dental records
- notes
- completed med hx
- consent documents
- correspondence eg referrals and reports
- notes of phone calls w pts
- radiographs, measurements, tracings
- digital records [incl CADCAM]
- dx images [radiographs, reports, casts]
- special test findings
pt details
- ID details : name, sex, DOB, address, email]
- completed and updated med hx incl adverse drug reactions [need to update if no changes to med hx]
- if child = need details of guardian/parent
clinical details
- date of visit
- details of practitioner
- type of exam conducted eg limited, periodic, comprehensive
- RFA in pt own words
- clinical findings
- discussion of adv/disadv
- med prescribed
other
- change of circumstance
- quotes/fees
- FTA + follow up action taken
purposes of keeping records
- clinical governance
- risk managment
- legislative obligations
- pt safety
- clinical changeover
- comms
- responsing to audits
- forensic reqs
- demonstrating collection of consent
- legal defence
- ceasing to treat
- managing adverse outcomes
describe the potential implications of poor record keeping
- can result in ordering of CPD, and determination of unsat professional conduct by DCNSW
- erode defence of civil claims [negligence]
- alternations made after the fact will likely elminiate available defence = exposing to risk of adverse findings and harming insurance coverage
list the legislation covering dental records
privacy act 1988 + privacy amendment 2012
limitation act 1969
aus health practitioner regulation national law 2010
describe the disposal of records
for adults
- need to retain for at least 7yrs from last visit
for < 18 yrs
- need to retain until indiv reaches at least 25yrs
