Albert Smith

Question 1

What is the GMC guidance on personal responsibility?

Answer 1

“You must not allow your views about a patient’s
lifestyle, culture, beliefs, race, colour, gender,
sexuality, age, social status or perceived economic
worth to prejudice the treatment you offer’…you
must not refuse or delay treatment because you
believe a patient’s actions have contributed to
their condition”

Question 2

Why keep medical records?

Answer 2

 As an aide mémoire for
clinicians
 To facilitate accurate and
effective communication with
other healthcare professionals
 For storage & recall of
background information
 For clinical governance
 To provide a legal record of
patient care

Question 3

Who owns medical records?

Answer 3

 The DoH – i.e. the government – owns the
records
 Patients do have the legal right to access the
records (in most cases)

 Private health service (BUPA etc)
 Depends on the contract
 Often owned by “client” (i.e. patient)

Question 4

Whats in clinical notes

Answer 4

 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 5

How do you write problem orientated medical notes?

Answer 5

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

Question 6

Norwells Ten Commandments of note keeping

Answer 6

 Notes to be legible
 Date and Time of Consultation
 Signed by name and printed underneath signature
 Use only approved/unambiguous abbreviations
 Never alter or disguise entries
 Must be edit trails on computer notes
 No insulting or ‘humorous’ comments
 See and evaluate notes thoroughly before filing
 Do not dispose of notes
 Protect the confidentiality of the medical record

Question 7

Duty when writing prescriptions?

Answer 7

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

Question 8

What are the laws regarding note keeping?

Answer 8

• Human Rights Act 1998
• Specifically art 8: respect for private & family
  life
• Data Protection Act 1998
• Confidentiality
  Protected by common law, not statue law –
  except where there is an overlap with the DPA
  1998.

Question 9

What does the Data Protection act say about note keeping?

Answer 9

 1st Principle: requires data processing to be fair to
the individual concerned and lawful in terms of
wider UK law.

 7th Principle: requires those responsible for
personal data to protect it against un-authorized
or unlawful processing.

 Section 55: makes it a criminal offence to obtain
or disclose personal data unlawfully

Question 10

Who gets access to medical records?

Answer 10

 Adult Competent Patients: can access unless will
come to serious harm or relates to another person

 Incapacitous adult: perhaps (and those with an
LPA in England/Wales can too)

 HCPs: Patients can constrain clinical info between
team [GMC para 10 “Confidentiality”] but unusual
and unhelpful

 Lawyers: consent necessary if not the pts lawyer.