consent + record keeping Flashcards
Why obtain consent?
1) respect patients’ rights
2) maintain an effective partnership between you + your patients
3) legal duty
What are the 2 types of consent?
1) explicit
2) implied
What is explicit consent?
when a patient gives you specific written or spoken permission to do something
What is implied consent?
when a patient indirectly implies their consent
What are the criteria for consent to be valid?
it must be voluntary + informed, + the person must have the capacity to make the decision
What is voluntary consent?
the decision to either consent/not to consent must be made by the person, + must not be influenced by pressure from medical staff, friends or family
What is informed consent?
the person must be given all information about what the treatment involved, including benefits + risks, whether there are reasonable alternative treatments, + what will happen if treatment does not go ahead
What is capacity with regards to consent?
the person must be capable of giving consent, which means they understand the information given to them + can use it to make an informed decision
When can a child give consent?
if you are satisfied the treatment is in their best interest, + you deem them to be competent
What is assent?
acceptance of treatment by someone that lacks mental capacity (can be deemed as assault)
What is dissent?
refusal of treatment by someone without sufficient mental capacity to make such decision
What is refusal?
refusal of treatment by someone with full mental capacity
When can sensitive personal data be disclosed?
1) prevention/detection of crime
2) protecting the public against dishonesty
3) malpractice
4) mis-management
5) incompetence
What are some forms of record keeping?
1) CD Registers
2) POM Registers/Emergency Supplies/Veterinary Supplies
3) The Pharmacy Record - Responsible Pharmacist (RP)
4) Electronic Health Records/Summary Care Record (SCR
5) Patient medication record (PMR)
