Documenting the Consultation Flashcards
What is a clinical documentation?
Making a clinical record
-> Histories, findings, referrals, prescribing decision, advice.
Why is clinical documentation important?
- Legal protection
- Effective communication between healthcare professionals
- Identify risks
- Effective clinical judgements and decisions
- Supports person care and communication
Should clinical records be made only for face-to-face consultations?
No, they should be made for every interaction.
What are some examples of things which should be documented at a consultation?
- Referrals
- Advice given to patient or Healthcare Professional
- Medicine prescribed/deprescribed, altered or reviewed
- A decision to do nothing
Why should you document if nothing was done in a consultation?
To show that the patient was assessed and this was the safest option.
What elements are part of a clinical record?
- Problem
- History (Medical, family, social)
- Examination
- Test/Procedures
- Medication
- Referrals
- Comments
- Follow-ups
What is principle 1 of the GPhC standards?
Procedures and records should help keep patients and the public safe.
What is principle 4 of the GPhC standards?
The way a pharmacy service works should help keep patients and the public safe.
Can patients see their full consultation information?
Yes, they now have access of their full records.
-> only information from 31st October 2023
What are the benefits of allowing patients to be able to access their full records?
- More understanding of their health
- Helps prepare for appointments
- Won’t need to contact GP for test results/updates
- Can flag if any inaccuracies
- Improve clinical outcomes
What are the 3 main types of situations where information that may be withheld from patient access?
- Harmful situation
- Confusing situations
- Confidential situations
What is cukooing?
When a vulnerable person’s home is taken over by exploiters.
When may access to records be denied?
Where it will cause serious harm or affects mental or physical wellbeing.
Give one example when refusing access is appropriate.
If a patient is in a coercive relationship and may be forced to show their records.
What are 3 examples of when access to records may be refused?
- Upsetting content
- Confidential information
- Malicious intent
How are access to records affected by changes in circumstances?
Information that was once acceptable for online access may no longer remain acceptable.
What should you do to the access to records if you think your patient may be in a coercive relationship?
- Speak to safeguarding lead
- Restrict access
- Document why
True or False: Patient’s must request for access to their medical records.
False, access to records are given to the patient by default unless there is a clear reason not to (risk/harm).
What can be done to records to show about a patient’s capacity or previous abuse?
There can be flags on patients notes
-> Discuss with patient
