Principle 4 - Maintain and Protect Patients' Information

Question 1

What is Principle Four?

Answer 1

Maintain and Protect Patients’ Information

Question 2

What do patinents expect with regards to principle four? (4)

Answer 2

• Their records to be up to date, complete, clear, accurate and legible
• Their personal details to be kept confidential
• To be able to access their dental records
• Their records to be stored securely

Question 3

What are the five standards within prinicple four? (5)

Answer 3

• 4.1 Make and keep contemporaneous, complete and accurate patient records
• 4.2 Protect the confidentiality of patients’ information and only use it for which it was given
• 4.3 Only release a patient’s information without thier permission in exceptional circumstances
• 4.4 Ensure that patients can have access to their records
• 4.5 Keep patients’ inofrmation secure at all times, whether your records are held on paper or electronically

Question 4

What must you keep each time you treat a patient?Give examples (8) of what forms part of patient records where they are available (4.1.1)

Answer 4

You must:

• Make and keep complete and accurate patient records, including an up-to-date medical history, each time that you treat patients
• Where available, the following all form part of patient records:
• – Radiographs
• – Consent forms
• – Photographs
• – Models
• – Audio or visual recordings of consultations
• – Laboratory prescriptions
• – Statements of conformitiy
• – Referral letters

Question 5

How much detail should there be in patient records? What should this include? (4.1.2)

Answer 5

• You should record as much detail as possible about the discussions you have with your patient
• Including evidence that valid consent has been obtained
• You should also include details of any particular patient’s treatment needs where appropriate

Question 6

What must you understand about your responsibilities? What must you do? (4.1.3)

Answer 6

You must:

• Understand and meet your responsibilities in relation to patient information in line iwth current legislation
• Follow appropriate national advice on retaining, storing and disposing of patient records

Question 7

How must your documentation be recorded? (4.1.4)

Answer 7

You must:

• Ensure that all documentation that records your work, including patient recrods, is clear, legible, accurate and can be readily understood by others
• Record the name or initial of the treating clinician

Question 8

How must amendments to a patient’s records be made? (4.1.5)

Answer 8

• You must make sure that the changes are clearly marked up and dated

Question 9

What should be done if you refer a patient to another dental professional or health professional? (4.1.6)

Answer 9

• You must make an accurate record of this referral in the patient’s notes and include a written prescription when necessary

Question 10

Why is confidentiality so important between clinician and patient? What does this apply to? (4.2.1)

Answer 10

• Confidentiality is central to the relationship and trust between you and your patients
• You must keep patient information confidential
• This applies to all the information about patients that you have learnt in your professional role including personal details, medical history, what treatment they are having and how much it costs

Question 11

Who must you ensure is aware of confidentiality in particular? (4.2.2)

Answer 11

• Non-registered members of the team must be aware of the importance of confidentiality and that they keep patient information confidential at all times

Question 12

What are the rules with information and social media? How can you post information on professional social media? (4.2.3)

Answer 12

• You must not post any information or comments about patients on social networking or blogging sites
• If you use professional social media to discuss anonymised cases for the purpose of discussing best practice you must be careful that the patient or patients cannot be identified

Question 13

When must you not talk about patinets or their treatment? (4.2.4)

Answer 13

• When you can be overheard by people who should not have access to the information you are discussing

Question 14

What must you explain to patients about sharing information? What does this include? (4.2.5)

Answer 14

• You must explain to patinets the circumstances in which you may need to share information with others involved in their health care
• This includes makign sure that they understand:
• – What information you will be releasing
• – Why you will be releasing it; and
• – The likely consequences of you releasing the information

Question 15

What are the rules on patients witholding permission to share information? (4.2.5)

Answer 15

You must:

• Give your patinets the opportunity to withhold their permission to share information in this way
• Unless exceptional circumstances apply
• You must record in your patient’s notes whether or not they gave their permission

Question 16

What must you ensure about the person you are sharing, the patient’s information, with? (4.2.6)

Answer 16

• Ensure that anyone you share it with undertands that it is confidential

Question 17

What must you do if other people ask you to provide information about patients (for example, for teaching or research) or if you want to use patient information such as photographs for any reason? (4.2.7)

Answer 17

You must:

• Explain to patients how the information or images will be used
• Check that the patients understand what they are agreeing to
• Obtain and record the patients’ consent to their use
• Only release or use the minimum information necessary for the purpose; and
• Explain to the patients that they can withdraw their permission at any time

Question 18

What must you do if it is not necessary for patients to be identified in provided information e.g. photographs? (4.2.7)

Answer 18

• Make sure they remain anonymous

Question 19

How long must you keep patinet information confidential? (4.2.8)

Answer 19

• You must keep patient information confidential even after patients die

Question 20

What does the duty to keep information confidential also cover? (4.2.9)

Answer 20

• Also covers recordings or images of patinets such as photographs, videos or audio recordings, noth originals and copies, including those made on a mobile phone
• You must not make any recordings or images without patients permission

Question 21

When may you be justified in releasing confidential patient information without the patient’s consent? When could this happen? (4.3.1)

Answer 21

• In exceptional circumstances, you may be justified in releasing confidential patient information without their consent if doing so is in the best interests of the public or the patient
• This could happen if a patient puts their own safety or that of others at serious risk, or if information about a patient could be important in preventing or detecting a serious crime

Question 22

What should you do if you believe that revealing information about a patinet is in the best interests of the public or the patient? (4.3.1)

Answer 22

• You should first try to get the patient’s permission to release the information
• You should do everything you can to encourage the patient to either release the information themselves or to give you permission to do so
• You must document the efforts you have made to obtain consent in the patient’s notes

Question 23

What should you do if obtaining consent from a patient to the release of thier information in the public interest is not practical or appropriate? Or if the patient will not give their permission? (4.3.2)

Answer 23

• Get advice from your defence organisation or professional association before you release the information

Question 24

What should you do if you have information that a patient is or could be at risk of significant harm, or you suspect that a patient is a victim of abuse? (4.3.3)

Answer 24

• You must inform the appropriate social care agencies or the police

Question 25

When can you be forced to release information about a patient without their permission? If this happens what should you do? (4.3.4)

Answer 25

• You can be ordered by a court, or you can be under a statutory duty, to release information about a patient without their permission
• If this happens, you should only release the minimum amount of information necessary to comply with the court order or statutory duty

Question 26

What must you do in any circumstances where you decide to release confidential information? (4.3.5)

Answer 26

• You must document your reasons and be prepared to explain and justify your decision and actions

Question 27

How must you ensure patients have access to their records? (4.4)

Answer 27

• Although patients do not own their dental records, they have the right to access them under Data Protection legislation
• If a patient asks for access to their records, you must arrange for this promptly, in accordance with the law

Question 28

Can you charge patients to access their records? (4.4.2)

Answer 28

• In some circumstances you can charge patients a fee for accessing their records
• The maximum you can charge depends on whether the records are paper copies or held electronically.
• You should check the latest guidance issued by you national Information Commissioner’s Office

Question 29

How should you store patients’ information? (4.5.1)

Answer 29

• You must keep patients’ information secure at all times, whether your records are held on paper or electronically
• You must make sure that patients’ information is not revealed accidentally and that no-one has unauthorised access to it by storing it securely at all times.
• You must not leave records where they can be seen by other patients, unauthorised staff or members of the public

Question 30

What should you do if you are sending confidential information? (4.5.2)

Answer 30

• You should use a secure method.

- If you are sending or storing confidential electronically, you should ensure that it is encrypted

Question 31

What should you do if clinical records are computerised? (4.5.3)

Answer 31

• You should make back-up copies of clinical records, radiographs and other images