L36: Legal issues for writing and documentation in practice

Question 1

What are the 5 main steps in legal issues for writing and documentation in practice?

Answer 1

1. Why am I writing
   
   1. Inadequate notes can be unprofessional conduct or conduct of a lesser standard
2. What is the question/problem?
   
   1. Safety/mobility
3. Facts and conclusions- the difference
   
   1. Must write in ordered fashion
   2. Start with facts and end on conclusions (need to be interconnected)
4. When are you required to draw conclusions
   
   1. When analysing conclusions, need to be lead back to facts (how did you get to be B when I can’t see how A relates to it/no factural basis)
5. Consider who may be the readers
   
   1. Lawyers
   2. Claim assessors, insurers
   3. Judges (need to draw their own conclusions when reading documentation)
   4. Someone else in the practice
   5. Patient or patient’s family

Question 2

What are 4 purposes or goals of step 1?

Answer 2

Why am I writing?

Think about the reason for writing

• Clinical notes for your practice
• Meeting professional standards
• A report or another health professional
• A legal report- giving expert opinion
• What is the issue that will be dealt with in court?

Different reasons require different approaches

• Progress (history) (what do you want to read if I picked up a file/patient from physio?
• What do you need to be clear about (if for other health professional)?

Question 3

What are 3 presenting problems/understanding question of step 2?

Answer 3

Question 4

What are facts? What makes them facts?

Answer 4

Facts

• Information used as evidence5 or as part of a report
• The truth about events as opposed to interpretations

This makes facts:

• Verifiable measurable things or things that happened
• Different to conclusion- what the facts mean

Question 5

What is the structure/conclusion of step 4?

Answer 5

Question 6

What i4 considerations of step 5?

Answer 6

Question 7

Who are 5 other readers of step 5?

Answer 7

Others readers: What is their interest

1. The patient - Privacy Act 1988- sensitive information
2. The patient can ask for access to the information (and the report/information)- so write on the basis that the patient themselves may read the document/report
3. Lawyers/judges
4. Insurers
5. Oher practitioner/medical practitioner

Question 8

What are characteristics of sensitive information for step 5?

Answer 8

Sensitive information is personal information that includes information or an oponion about an individual’s:

• Racial or ethnic origin
• Political opinion or associations
• Religious or philosocphical beliefs
• Trade union membership or associations
• Sexual orientation or practices
• Crimical record
• Health or egneric information
• Some aspects of biometric information

Sensitive

XXX

Question 9

What are characteristics of am I protected for step 5?

Answer 9

• Did I wrote for the reason I was meant to write
• Did I answer the questions(s), did I ignore the questions(s) or did I go for more than the question and try to show how much I know (writing in professional practice is not the same as answering an exam question)