W8: Medical records and the Coroner's court Flashcards
(45 cards)
what is confidentiality?
Protecting a patient’s personal and medical information, only sharing it with authorized individuals involved in their care, and with the patient’s consent.
What are some of the benefits of the confidentiality legislation?
a) to balance the public interest in protecting the privacy of
health information with the public interest in the legitimate use
of that information, and
b) to enhance the ability of individuals to be informed about their
health care, and
c) to promote the provision of quality health services
d) minimise misuse and inappropriate disclosure of information ,
and
e) to provide the employees with the ability and knowledge to
safely secure and protect sensitive, confidential and
appropriately classified information, and
f) to promote the appropriate fit-for-purpose information
management governance models and mechanisms.
What is privacy
A duty to protect the personal information of other from being
accessed by others
How does the confidentiality legislation help to promote fair and responsible handling of health information?
a) protecting the privacy of an individual’s health information
that is held in the public and private sectors, and
b) enabling individuals to gain access to their health
information, and
c) providing an accessible framework for the resolution of
complaints regarding the handling of health information.
d) enhance public reporting and provide accountability in the
health system.
What are the consequences of breaches of confidentiality?
❑ Reporting the individuals responsible for the breach to the employer
❑ Reporting to the external nursing authorities
❑ Reporting allegations of criminal conduct to the police
What to consider with disclosure regarding confidentiality
Proceed with caution when disclosing confidential information without patient consent.
Remember: Patients have the legal right to access their medical records and health information
What questions to ask regarding disclosure?
Do you have the patient’s consent? If yes, who is authorized to receive the information?
If no, under what circumstances can information be released to third parties?
What information can be provided to the Coroner?
- A person who reports a death must give to the coroner investigating
the death any information which may help the investigation. - A member of the police force who has information relevant to an
investigation must report it to the Coroner investigating the death.
What are the 3 ways when we are authorised to disclose a patient confidential informatioN:
❑ With consent:
❑ By operation of the law:
❑ In the public interest (For example if the patient is at risk of
harm to self or others)
What is a common way that considered breaching of confidentiality?
❑ one of the most common mistakes nurses make is believing their
decision not to name a patient means they are not breaching patient
privacy or confidentiality.
❑ Example: talking about a patient on a bus and a person recognises
who you are talking about
What are the 2 aspects if good communication?
❑ The manner of communication.
❑ The quality of the information communicated
What is a medical record?
A medical record is considered a contemporaneous record of
events, and can be admitted as evidence in:
❑ Civil proceedings.
❑ Criminal proceedings.
❑ Coronial inquiries
What are the legal requirements for communication in nursing care in Australia?
Nurses must ensure that communication is clear, accurate, and timely, adhering to confidentiality and privacy laws while maintaining comprehensive and factual documentation in patient records.
What constitutes a contemporaneous record in nursing?
A contemporaneous record is a detailed, accurate entry made as close as possible to the time of the event, including date, time, signature, and designation of the writer.
Why is accurate documentation crucial in nursing care?
Accurate documentation provides a legal record of patient care, supports continuity of care, reduces the risk of miscommunication, and serves as evidence in legal proceedings.
How should errors in medical records be corrected?
Errors should be crossed out with a single line, the correction noted, and the entry initialled and dated without obliterating the original information.
What is the primary role of the Coroner’s Court in Australia?
The Coroner’s Court investigates reportable deaths to determine the identity, date, place, cause, and manner of death and provides recommendations to prevent future occurrences.
What types of deaths must be reported to the Coroner?
Deaths that are violent, unnatural, sudden without known cause, or not reasonably expected due to a medical procedure.
What is the role of the nurse when a reportable death occurs?
Nurses must ensure accurate documentation, maintain all medical devices in situ, prepare the body appropriately, and provide statements or evidence if required.
Can nurses be subpoenaed to give evidence in the Coroner’s Court?
Yes, nurses may be required to provide factual evidence based on their records or observations related to the patient’s care.
How does the Coroner’s Court contribute to public health and safety?
The Coroner’s Court can make recommendations to prevent future deaths and improve healthcare practices based on investigation findings.
What are the legal requirements for creating patient records in nursing practice?
Patient records must be accurate, complete, contemporaneous, and include only factual and clinical information relevant to the patient’s care.
How should patient records be securely stored?
Records must be stored in secure, access-controlled systems, whether electronic or physical, to prevent unauthorised access, loss, or damage.
What are the risks of improper record management?
Incomplete, inaccurate, or missing records can lead to legal liability, compromised patient care, and breaches of patient confidentiality.
