clinical confidentiality

Question 1

what is the role of clinical records in clinical practice?

Answer 1

admin and management
legal compliance
clinical audit
clinical research
clinical evidence

Question 2

what is appropiate clinical content to maintain?

Answer 2

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

Question 3

what would be representive of good record keeping?

Answer 3

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

Question 4

what is the essential content to maintain in clinical records?

Answer 4

• Subjective, i.e., Clinical Information from the Patient;
• Objective, i.e., Clinical Examination of the Patient;
• Assessment, i.e., Clinical Diagnosis & Prognosis; and
• Problem List and Plan, i.e., Clinical Management & Care Plan

Question 5

how would you professionally maintain clinical records?

Answer 5

clear
objective
contemporaeous
attrubutable
original

Question 6

what is the clinical record keeping procedure?

Answer 6

• Signature, Name (Capitals), & Counter Signature;
• Date & Time of Alterations and/or Deletions;
• Reason for Alteration and/or Deletion

Question 7

what would be considered for non-use of clinical abbreviations?

Answer 7

• Patient Transfer;
• Patient Discharge;
• External Consultant Referral Letters;
• Consent Forms;
• Death Certificates;
• Incident Report Forms; and
• Trust Communications

Question 8

what are the clinical risk management issues?

Answer 8

• Non-Record of Negative Clinical Findings;
• Non-Record of Details of Consultation;
• Non-Record of Drug Allergies or Adverse Clinical Reactions;
• Non-Record of Clinical Investigation & Test Results;
• Non-Correction of Illegible Entries;
• Non-Referral to Clinical Records in Patient Consultation;
• Non-Removal of Derogatory Remarks; or
• Failure to Double Check Patient Subject Matter

Question 9

what is involved in the clinical records and clinical disclosure procedure?

Answer 9

• Anonymisation or Codification;
• Patient Informed Consent;
• Minimisation; and
• Legal Compliance (Clinical Confidentiality)

Question 10

what would be classed as clinical records and inappropiate disclosures?

Answer 10

• Non-Discussion in Public Place or Social Media;
• Non-Sharing of Computer Passwords; and
• Raise Patient Safety & Information Governance Concerns

Question 11

what would be considered in administrative and professional considerations?

Answer 11

• Nature of Clinical Information;
• Proposed Use of Clinical Information;
• Prospective Recipients of Clinical Information;
• Clinical Confidentiality & Security Arrangements; and
• Potential for Distress or Harm

Question 12

what would the clinical procedure be for absence of patient mental capacity?

Answer 12

• Advance Healthcare Planning Review;
• Patient Legal Power of Attorney Consultation; or
• Family, Friends or Carers Consultation

Question 13

what would be involved in the disclosure of clinical info of a diceased patient for legal admin or clinical purposes?

Answer 13

• Coroner’s Court Hearing;
• Death Certificates;
• Public Health Surveillance;
• Parental Enquiries (Neo-Natal or Paediatric Death); or
• Formal Request of Deceased Patient Spouse, Next of Kin, or
Legal Representative

Question 14

define confidential information

Answer 14

A Pharmacist must use the Patient’s Clinical Information
in compliance with the General Pharmaceutical Council’s, GPC’s
Guide on Professionalism, “Code of Standards”, and the Legal
Doctrine of Clinical Confidentiality.

Question 15

what are the legal categories of confidential information?

Answer 15

• Personal;
• Government;
• Commercial; and
• Medical

Question 16

what action would be taken in breach of confidence patient clinical information?

Answer 16

• Confidential in Nature;
• Exchanged in Clinical Consultation; and
• Disclosed in Unauthorised Manner

Question 17

who is a data controller/patient, personal data and medical record in relation to the GDPR and data protection act 2018?

Answer 17

data controller= pharmacist
• Data Subject = Patient;
• Personal Data = Patient Clinical Information
• Medical Record = Physical & Mental Health
Factual & Professional Opinion
Electronic & Manual Form

Question 18

what is in the clinical and personal information in clinical records?

Answer 18

• Clinical Consultation Notes;
• Referral & Discharge Letters;
• Clinical Tests Results;
• Video & Audio Recordings;
• Clinical Samples; and
• Clinical Reports for Third Parties

Question 19

what are the data protection principles in the data protection act 2018?

Answer 19

• Be Processed Lawfully, Fairly, & Transparently;
• Be Processed for Specified, Explicit, & Legitimate Purposes;
• Be Adequate, Relevant & Limited to Necessary Purposes;
• Be Accurate & Up to Date;
• Not Be Stored for Longer than Necessary; and
• Be Stored Safely & Securely

Question 20

what are the conditions of the data processing?

Answer 20

• 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; and
• Legitimate Interests of the Data Controller or Third Party;

Question 21

what is involved in admin, professional maintenance of clinical record?

Answer 21

• Clear, Accurate, Factual, Legible &
Contemporaneously Recorded;
• Clinical Findings, Treatment Decisions, &
Patient Clinical Information;
• No Personal Views or Derogatory Remarks;
• Facilitate Patient Access to Clinical Records;
• No Amendment/Change unless Correct or Remove Misleading or
Inaccurate Clinical Information; and
• No Amendment/Change at Patient/Patient Family’s Request

Question 22

what is involved in patient informed consent?

Answer 22

• Voluntary;
• Specific & Informed;
• Unambiguous (Statement/Clear Affirmative Action); and
• Right to Refuse/Withdraw

Question 23

what is involved in a subject access request?

Answer 23

• Mental Capacity, Mature Minors, Young People, Next of Kin &
Solicitors;
• Made Electronically, In Writing and Verbally;
• Identity Verification by Reasonable Means in Twenty-Eight Days;
• Patient Consultation on Disclosure, i.e., Full, Tailored or Limited;
• Refusal if “Manifestly Unfounded or Excessive”;
• Provided in Electronic or Manual Format & Fees Payable; and
• Explanation of Clinical Terms

Question 24

what is involved in the grounds for refusal of subject access request?

Answer 24

• Prevent Physical/Mental Harm to Patient or Third Party;
• Protect Clinical Confidentiality of Third Party &
Legal Professional Privilege; or
• Restricted by Law or Court Order

Question 25

who can subject access request as a third party?

Answer 25

• Parents;
• Legal Power of Attorney & Legal Estate of Deceased;
• Police; and
• Insurers

Question 26

what are the two laws that govern clinical confidentiality and related legislation?

Answer 26

• Human Rights Act 1998
(Right to Privacy); and
• Freedom of Information Act 2000
(Right of Access to Records of Public Authorities)