Medical Confidentiality Flashcards
role of medical records in clinical practice
administration and management
legal compliance
clinical audit
clinical research
clinical evidence
maintenance of medical records: appropriate clinical content
x-rays and clinical imaging
photos
audio and video recordings
patient monitoring printouts
patient consent forms
maintenance of medical records: good record keeping
differential diagnosis
clinical investigations
clinical referrals
clinical information
patient consent process
medical treatment plan
clinical follow up
patient care plan
maintenance of medical records: essential content
subjective
objective
assessment
problem list and plan
subjective
medical information from the patient
objective
medical examination of the patient
assessment
medical diagnosis and prognosis
problem list and plan
medical management and care plan
professional maintenance of medical records
clear
objective
contemporaneous
attributable
original
medical record correction procedure
signature, name (capitals), counter signature
sate and time of alterations/ deletions
reason for alterations/deletions
non-use of clinical abbreviations
patient transfer
patient discharge
external consultant referral letters
consent forms
death certificates
incident report forms
trust communications
clinical risk management issues
non-record of:
-negative clinical findings
-details of consultation
-drug allergies/adverse clinical reacitons
-clinical investigation and test results
risk management issues
non-correction of illegible entries
non-referral to medical records in patient consultation
non-removal of derogatory remarks or failure tot double check patient subject matter
medical records and clinical disclosure procedure
anonymisation or codification
patient informed consent
minimisation
legal compliance
medical records and inappropriate disclosures
non-discussion in public place/social media
non-sharing of computer passwords and raise patient safety and information governance concerns
disclosure of patient clinical information: administrative and professional considerations
nature of clinical information
proposed use of clinical information
prospective recipients of clinical information
medical confidentiality and security arrangements and potential for distress or harm
disclosure of patient clinical information: clinical procedure for absence of patient mental capacity
advance healthcare planning review
patient legal power of attorney consultation or family/friends/carers consultation
disclosure of clinical information of a deceased patient: administrative legal or clinical purposes
coroners court hearing
death certificates
public health surveillance
parental enquiries (neo-natal/ peadiatric death) or formal request of deceased patient spouse, next of kin or legal representative
legal definition of confidential information, Lea on medical confidentiality
A Medical Practitioner must use the Patient’s Clinical Information
in compliance with the General Medical Council’s, GMC’s, Guide on
Professionalism, “Good Medical Practice”, and the Legal Doctrine of
Medical Confidentiality
legal categories of confidential information
personal
government
commercial
medical
action for breach of confidence: patient clinical information
confidential in nature
exchanged in clinical consultation
disclosed in unauthorised manner
lion laboratories v evans
(Protecting General Public from Unlawful Arrest and Prosecution)
X v Y & Others
(Protecting Confidentiality of Medical Records outweighs PublicInterest in Freedom of the Press)
Tarasoff v Regents of University of California
(Protecting General Public outweighs Protective Clinical Privilege)
Lipari v Spears
(General Legal Duty to Predict Danger & Protect Society)
Brady v Hopper
Legal Duty Limited to Specific Threats to Specified Individuals)
W v Egdell
(Legal Duty to Protect General Public from Serious Harm or Injury)
Palmer v Tees Health Authority
(Legal Duty Limited to Special Relationship with Identifiable Victim)
W v Egdell
(Common Law Duty of Medical Confidentiality
McInerney v McDonald
(Fidiuciary Relationship & Mutual Trust)
McInerney v McDonald
(Medical Information Personal Property of Patient)
R v Mid Glamorgan FHSA & South Glamorgan Health Authority
(Medical Interpretation & Medical Diagnosis
Professional Property of Medical Practitioner)
data controller
medical practitioner
data subject
patient
personal data
patient clinical information
medical record
physical and mental health
factual and professional opinion
electronic and manual form
clinical and personal information in medical records
clinical consultation notes
referral and discharge letters
clinical tests results
video and audio recordings
clinical samples
clinical reports for third parties
data protection principles
be processed lawfully, fairly and transparently
be processed for specified, explicit and legitimate purposes
be adequate, relevant and limited to necessary purposes
be accurate and up to date
not be stored for longer than necessary
be stored safely and securely
conditions for 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
legitimate interests of the data controller or third part y
administrative and professional maintenance of medical records
clear, accurate,factual, legible and comtemporaneously recorded
clinical findings, treatment decisions and patient clinical information
no personal views or derogatory remarks
facilitate patient access to medical records
no amendment/change unless correct or remove misleading or inaccurate clinical information
no amendment/change at patient/familt request
patient informed consent
voluntary
specific and informed
unambiguous
right to refuse/withdraw
subject access request
mental capacity, mature minors, young people, next of kin and solicitors
made electronically, in writing and verbally
identity verification by reasonable means in 28 days
patient consultation on disclosure
refusal if manifestly unfounded or excessive
provided in electronic or manual format and fees payable
explanation of clinical term
grounds for refusal of subject access request
prevent physical/mental harm to patient or third party
protect medical confidentiality of third part and legal professional privilege
restricted by law or court order
subject access request and third parties
parents
legal power of attorney and legal state of deceased
police
insurers
