clinical confidentiality Flashcards
what is the role of clinical records in clinical practice?
admin and management legal compliance clinical audit clinical research clinical evidence
what is appropiate clinical content to maintain?
x-rays and clinical imaging photographs audio and video recordings patient monitoring printouts patient consent forms
what would be representive of good record keeping?
differential diagnosis clinical investigations clinical rederrals clinical information patient consent process clinical treatment plan clinical follow up patient care plan
what is the essential content to maintain in clinical records?
- 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
how would you professionally maintain clinical records?
clear objective contemporaeous attrubutable original
what is the clinical record keeping procedure?
- Signature, Name (Capitals), & Counter Signature;
- Date & Time of Alterations and/or Deletions;
- Reason for Alteration and/or Deletion
what would be considered for non-use of clinical abbreviations?
- Patient Transfer;
- Patient Discharge;
- External Consultant Referral Letters;
- Consent Forms;
- Death Certificates;
- Incident Report Forms; and
- Trust Communications
what are the clinical risk management issues?
- 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
what is involved in the clinical records and clinical disclosure procedure?
- Anonymisation or Codification;
- Patient Informed Consent;
- Minimisation; and
- Legal Compliance (Clinical Confidentiality)
what would be classed as clinical records and inappropiate disclosures?
- Non-Discussion in Public Place or Social Media;
- Non-Sharing of Computer Passwords; and
- Raise Patient Safety & Information Governance Concerns
what would be considered in administrative and professional considerations?
- Nature of Clinical Information;
- Proposed Use of Clinical Information;
- Prospective Recipients of Clinical Information;
- Clinical Confidentiality & Security Arrangements; and
- Potential for Distress or Harm
what would the clinical procedure be for absence of patient mental capacity?
- Advance Healthcare Planning Review;
- Patient Legal Power of Attorney Consultation; or
- Family, Friends or Carers Consultation
what would be involved in the disclosure of clinical info of a diceased patient for legal admin or clinical purposes?
• 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
define confidential information
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.
what are the legal categories of confidential information?
- Personal;
- Government;
- Commercial; and
- Medical
what action would be taken in breach of confidence patient clinical information?
- Confidential in Nature;
- Exchanged in Clinical Consultation; and
- Disclosed in Unauthorised Manner
who is a data controller/patient, personal data and medical record in relation to the GDPR and data protection act 2018?
data controller= pharmacist
• Data Subject = Patient;
• Personal Data = Patient Clinical Information
• Medical Record = Physical & Mental Health
Factual & Professional Opinion
Electronic & Manual Form
what is in the clinical and personal information in clinical records?
- Clinical Consultation Notes;
- Referral & Discharge Letters;
- Clinical Tests Results;
- Video & Audio Recordings;
- Clinical Samples; and
- Clinical Reports for Third Parties
what are the data protection principles in the data protection act 2018?
- 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
what are the conditions of the data processing?
• 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;
what is involved in admin, professional maintenance of clinical record?
• 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
what is involved in patient informed consent?
- Voluntary;
- Specific & Informed;
- Unambiguous (Statement/Clear Affirmative Action); and
- Right to Refuse/Withdraw
what is involved in a subject access request?
• 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
what is involved in the grounds for refusal of subject access request?
• 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
who can subject access request as a third party?
- Parents;
- Legal Power of Attorney & Legal Estate of Deceased;
- Police; and
- Insurers
what are the two laws that govern clinical confidentiality and related legislation?
• Human Rights Act 1998
(Right to Privacy); and
• Freedom of Information Act 2000
(Right of Access to Records of Public Authorities)
