Consent and record keeping

Question 1

who is interested in the clinical records?

Answer 1

• patients (if going to another practice)
• colleagues (if colleagues don’t turn up and you need to see pt instead)
• health board/SDCEP (check if you are providing the care you claim)
• GDC (use records to determine if issue raised is worth investigating)
• GDPR
• civil litigation lawyer/malpractice/negligence

Question 2

what is GDC priniple 4?

Answer 2

maintain and protect patient’s information
* keep complete and accurate patient records in as much detail as possible
* ensure they are clear, legible, accurate and can be readily understood by others
* patients have a right to access thier records under the Data Protection legislation
* confidentiality is central to the trusted relationship between you and the patients

Question 3

how long should record be kept after last contact with a patient?

Answer 3

10 years

Question 4

how long should records be kept when an adult patient dies?

Answer 4

3 years

Question 5

how long should records be kept when a person dies before their 17th birthday?

Answer 5

records should be kept until their 25th birthday

Question 5

what types of record are covered by the Code of Practice?

Answer 5

records in any format
* paper
* electronic
* microfilm
* audio
* SMS
* emails
* social media
* website content
* voice recording

Question 6

what sholud storing and scanning NHS records ensure continuation of?

Answer 6

• integrity
• reliability
• authenticity
• accessibility
• including the time of their disposal or archival preservation

Question 7

when can disclosure of condifential information be accepted?

Answer 7

• if the information provider has consented
• if it is required by law, or in response to a court order
• if it is justified in the public interest

Question 8

what does data protection legistlation say personal data should be?

Answer 8

• processed lawfully, fairly and in a transparent manner
• collected for specified, explicit and legitimate purposes
• adequate, relevant and limited to what is necessary
• accurate and where necessary kept up to date
• kept in a form which permits identification for no longer than necessary
• processed in a manner that ensures appropriate security of the personal data

Question 9

what is the Computer Misuse Act 1990?

Answer 9

• protects computer programmes and data against unauthorised access or alteration so only authorised users have permission to use certain programmes and data
• it is a criminal offence under the act to gain unauthorised acccess to computer material
• may inlude using another person’s ID and password without authority

Question 10

what should be included in clinical records?

Answer 10

• date
• C/O
• M/H check
• FTA - failed to attend
• WNB - was not brought (children)
• treatment

Question 11

what is written consent needed for?

Answer 11

• providing sedation
• if under GA

Question 12

what is important to consider when with a patient?

Answer 12

• give patients permission to say no
• consider giving post-op instructions pre-op incase it changes a patient’s decisions
• accept a patient’s timetable may not match yours
• ask questions (S/H)
• do not make assumptions