Vulnerable consults, Legal, Administration and Practice issues

Question 1

What are key features that the Practice’s Results Policy should cover?
i.e when a patient result is received

Answer 1

1. The responsibility for checking the result lies with the doctor that ordered it
2. Results should be reviewed by a doctor on a frequent basis
3. The practice should outline how they recall patients with urgent results
4. Practice should know which clinical staff can give results to a patient
5. Practice should have reminder systems in place
6. How to handle results when a colleague is away
7. procedure of following up with patients with significant abnormal results who have not responded to initial contact
8. Adequate documentation about results conveyed
9. Should have a dedicated staff member to check on recalls on a regular basis to make sure all abnormal results have been actioned

Question 2

After a seizure what is the recommendation for driving?

Answer 2

Non driving period for at least 6 months

the default however is 12 months of no driving unless it’s a first seizure of any time or epilepsy treated for the first time, then..

at 6 months can be considered for a conditional licence, depending on the type of seizure or condition the seizure occurred in

Question 3

Workers compensation: what can you do in the GP consult to intervene and progress return to work?

Answer 3

1. Educate and reassure about the normal course of the disease
2. Use Active listening to acknowledge concerns
3. Challenge unhelpful beliefs like catasrophising
4. Administer a psychological screen to assess risk of poor outcomes
5. Communicate expectations for recovery and work
   “i expect that in 4 weeks you’ll be ready to return to work:
6. Can request a case conference with employer
7. Can Contact the employer to understand ability to accommodate reduced
   work capacity.

Question 4

What psychological factors can prevent someone returning to work
“yellow flags”

Answer 4

Fear of pain

High pain disability

Prominent psychological distress: anxiety and depressive symptoms

Poor belief in their own self management

High perceived disability

takes a passive role in recovery

Low resilience, inability to cope

Question 5

After a severe hypoglycaemic event how long, at the least is the patient not allowed to drive for?

Answer 5

“no recent history of a severe hypoglycemic event” equats to about 6 weeks

Question 6

Can a person treated with insulin have an unconditional licence?

Answer 6

No, will need annual review by either GP or endocrinologist, therefore conditional.

Question 7

When can you institute the mental health act?

Answer 7

When you need a psychiatric assessment and the patient is not willing in a person who
appears to be mentally unwell and poses or
substantial risk to themselves or others
AND
it is reasonable to believe the treatment will reduce those risks.

Whereas violent outbursts without mental health disorder is a police matter.

Question 8

What restrictions on driving are there, with T2DM?

Answer 8

For private vehicles
Without insulin- no restrictions

With glucose lowering medication and insulin - conditional licence subject to periodic review especially with regard to end organ failure and risk of hypos or if there have been hypos. If so would need a specialist/endocrinologist to provide the review.

For commercial/heavy vehicle licences:
Without insulin- no restrictions

With insulin or glucose lowering medication - needs specialist review annually. (not metformin).

Cannot drive within 6 weeks of having a hypo

Question 9

What classifies as a ‘severe hypoglycemic event’ that would effect driver’s licencing?

Answer 9

a ‘severe hypoglycaemic event’ is defined as an event of hypoglycaemia of sufficient severity such that the person is unable to treat the hypoglycaemia themselves and so requires someone else to administer treatment. It includes hypoglycaemia causing loss of consciousness or seizure. It can occur during driving or at any other time of the day or night. A severe hypoglycaemic event is particularly relevant to driving because it affects brain function and may cause impairment of perception, motor skills or consciousness. It may also cause abnormal behaviour.

Question 10

Are you allowed to drive on a private vehicle licence with Parkinson’s Disease?

Answer 10

Can actually hold an UNCONDITIONAL licence if impairment is low

A conditional licence with annual review may be required for higher degrees of functional physical impairment. And a practical driving test might be warranted.

Question 11

Can you drive a commercial vehicle with parkinson’s disease?

Answer 11

Would need a conditional licence with specialist input and potential driving test. But yes a person can still have a licence.

Question 12

After intracranial surgery, what are the rules regarding driving?

Answer 12

Private - no driving for 6 months, and then seemingly can drive. but must not have ongoing seizures or neurological deficits

Commercial/heavy - no driving for 12 months. seemingly can drive after that but must not have seizures/neurological deficits.

If there are seizures / neurological deficits then refer to that criteria.

Question 13

What are the licensing conditions for somebody with dementia?

For light vehilces

Answer 13

Cannot hold an unconditional licence if there is a diagnosis of dementia.

Can have a conditional one, with annual review and input from treating doctor plus results of a driving test.

Question 14

What is NOT needed, though commonly presumed, in order to classify something as a non-accidental injury?

Answer 14

Intent to harm.

Proof of intention to cause harm is not required for a child’s injury to be judged nonaccidental. In the example of spanking example there may have been no intention to cause significant injury, but if significant tissue damage occurs it is nonaccidental.

Question 15

There is a grey zone for classifying non-accidental injury to a child.

What does this include?

(3)

Answer 15

Physical injury to a child might occur as a result of:
-an adult’s failure to provide adequate supervision,
-failure to provide a safe environment
-failure to discourage engagement in dangerous activities.

Question 16

Skin is the most common site of non-accidental injury.

A. What might you find?

(4)

B. What other skin manifestations might you see?
(2)

Answer 16

A.
Inflammation

Bruises

Abrasions

Lacerations

B. Burns and Scalds

Question 17

When are bruises on a child, a concern?

(5)

Answer 17

Childhood bruises are common on the front of the body and on bony prominences

Worrying signs:

• bruises on a premobile child
• Bruising on protected parts: ears, neck, trunk and buttocks

-Pattern shaped brusing

-Bruises interspersed with abrasions (such as caused by rope)

-non facial petechiae

Question 18

What does the colour of wound indicated about the time it has been there?

Answer 18

Mostly nothing

Research over the past decade has discredited many myths about aging of bruises. The age of a bruise cannot be determined from its colour other than to say that ‘yellowing’ has not been observed in bruising sustained less than 18 hours previously.

Question 19

Would a clavicular fracture be concerning for a non-accidental injury?

Answer 19

No, it’s not likely that clavicular fractures are caused by a non-accidental injury

Neither are linear skull fractures or a long bone fracture

Question 20

What fractures are concerning/most associated with a non-accidental injury?

(4)

Answer 20

1. Classic metaphyseal lesions (picture) - when extremity is pulled or twisted or when child is shaken
2. Posterior rib fracture
3. Scapular fractures
4. Sternal fractures

Question 21

What inconsistencies or features of history might make a GP suspicious of a non-accidental injury?

(5)

Answer 21

1. Delay in seeking medical treatment for significant injury
2. Explanation of injury cause changes over time without apparent reason
3. Explanation of injury cause differs between caregivers without apparent reason
4. Explanation offered is inconsistent with child’s
   developmental capabilities
5. Possible impairments to caregivers’ capacity to
   supervise and protect the child

Question 22

The term ‘child abuse and neglect’ is used to refer to:

any act or __(a)___ of care by a parent or other caregiver that results in harm, the potential for harm or the threat of harm to a child

or

any intentional and non-intentional behaviours by parents, caregivers or other adults considered to be in a position of responsibility, trust or power that results in a child being harmed physically or __(b)___.

Answer 22

a. omission

b. emotional

Question 23

What are the 5 categories of child abuse?

(5)

Answer 23

1. physical
2. emotional.
3. Sexual
4. neglect
5. exposure to domestic violence

Question 24

What classifies as neglect of child?

(5)

Answer 24

failure to provide adequate nutrition, hygiene or shelter

failure to ensure a child’s safety, which can include failure to provide adequate food, clothing or accommodation

not seeking medical attention when needed

allowing a child to miss long periods of school

failure to protect a child from violence in the home or neighbourhood or from avoidable hazards.

Question 25

What does the WHO LIVES acronym help you address with Intimate partner abuse and violence?

Answer 25

This is a good way to approach a first response to IPAV

“LIVES”

Listen: listen closely with empathy, non-judgemental

Inquire. And respond to their various needs: physical, emotional, social and practical

Validate: Show that you believe

Enhance. Discuss a safety plan

Support: Connect person with appropriate services, information and social support

Question 26

List at least 3 questions you can ask to address/raise the issue of intimate partner violence.

There are numerous.

Answer 26

‘How are things at home?’

‘Do you feel safe at home?’

‘Often people who have these types of health problems are experiencing difficulties at home. Is this happening to you?’

‘Sometimes these symptoms can be associated with having been hurt in the past. Did that ever happen to you?’

‘Has your partner physically threatened or hurt you?’

‘Is there a lot of tension in your relationship? How do you resolve arguments?’

‘Sometimes partners react strongly in arguments and use physical force. Is this happening to you?’
‘Are you afraid of your partner? Have you ever been afraid of any partner?’

‘Have you ever felt unsafe in the past at home?’

‘Violence is very common in the home. I ask a lot of patients about abuse because no-one should have to live in fear of their partners.’

‘Has your partner ever controlled your daily activities?’

‘Has your partner ever threatened to physically hurt you?’

Question 27

Coercive control is a pattern of acts that aim to cause __(a)___ and may include social control, whereby a survivor is isolated from friends or family, and ___(b)____ abuse, which could involve a survivor’s movements being tracked, their messages and emails being monitored, or sexting.

Mental health coercion may involve threatening __(c)___ to manipulate a victim/survivor. Migrant and refugee women may be manipulated by their partners based on their __(d)___ status.

Answer 27

a. fear

b. technology- assisted

c. suicide

d. visa

Question 28

What components make up the “safety planning guide” when dealing with intimate partner violence or even for child abuse.

(5)

Answer 28

1.Safe communication: who has access to your social media and phone. Do you have a safeword/codeword.

2. Safe place to go; Is there a friend/relative or other place they can go to to feel safe?
3. Transport. How would they get to that safe place?
4. Items to take: put a bag together with items you might need: clothes, money, toothbrush, chargers.
5. Support
   Friend, neighbour or family member that can help when things get really bad at home

Question 29

In cases where you have serious concern for the immediate safety of a child, a __(a)__ is mandatory.

If an adult discloses abuse or neglect of a baby or child, GPs are ___(b)__ ______ to examine the baby or child before making a report to a child protection service.

Answer 29

A. report

B. NOT required

Question 30

For babies what are some risk factors for child abuse?

(7)

Answer 30

1. Poor maternal attachment to the infant
2. household or family violence
3. Unstable housing of financial situation
4. mental health disorders of the parents or even intellectual disability
5. Use of hazardous drugs or alcohol in the house
6. history of own abuse or neglect or that of another child in the family.
7. Significant health needs of the baby (if they are seriously unwell and need more attention that anticipated)

Question 31

What tool can you use to asses elder abuse?

Answer 31

EASI tool

elder abuse suspicion index questionnaire

Question 32

List at least 4 of the 6 questions that can be asked if suspecting Elder Abuse?

Answer 32

1. Have you relied on people for any of the following: bathing, dressing, shopping, banking or meals?
2. Has anyone prevented you from getting food, clothes, medication, glasses, hearing aids or medical care, or from being with people you want to be with?
3. Have you been upset because someone talked to you in a way that made you feel shamed or threatened?
4. Has anyone tried to force you to sign papers or to use your money against your will?
5. Has anyone made you feel afraid, touched you in ways that you did not want, or hurt you physically?
6. Doctor: “Elder abuse may be associated with findings such as: poor eye contact, withdrawn nature, malnourishment, hygeine issues, cuts, brusies, inappropriate clothing, or medication compliance issues. Did you notice any of these today or in the last 12 months?”

Question 33

What general behavioural queues might alert you to elder abuse?
List at least 5

(10)

Answer 33

Being afraid of one or many person/s

Irritable or easily upset

Worried or anxious for no obvious reason

Depressed, apathetic or withdrawn

Change in sleep patterns

Change in eating habits

Rigid posture and avoiding contact

Avoiding eye contact or eyes darting continuously

Contradictory statements not from mental confusion

Reluctance to talk openly

Question 34

Who can GPs ring for help with elder abuse?

Answer 34

Elder Abuse Hotline (state based)

Question 35

What steps can you take to deal with a direct patient complaint?

(6)

Answer 35

Where possible (and appropriate) make personal contact by phone when you receive the complaint
Preferably ask for the complaint in writing

Before replying in writing, ring the patient and clarify the concerns

Deal promptly with the complaint

If there is to be a delay in responding, let the patient know and give a time frame

Show empathy to the patient even if you do not accept the basis of the complaint

Let the patient know what has been done to improve systems and processes at your practice as a result of their complaint

Question 36

When prescribing a drug of dependence, after what time frame do you need to apply for a state authority?

Answer 36

If the drug will be used for longer than 2 months.

Question 37

All prescriptions for schedule 8 drugs must include

Answer 37

name and address of the prescriber and the patient

description of the medication

quantity of the medication in words and numbers

precise directions for use

number of repeats and intervals at which they may be dispensed

signature of the prescriber.

Question 38

Can only one doctor prescribe a schedule 8 drug?

Answer 38

One doctor needs to apply for the Authority.
However anyone in the practice can prescribe the medication. They must however check the authority prior to prescribing.

Question 39

What are your obligations to a new patient who requests a drug of dependence?

(7)

Answer 39

Take a relevant history and examine the patient.

Determine whether you believe there is a clinical need to prescribe the drug.

Consider any alternative strategies that could be implemented or have been attempted.

Contact the patient’s usual/previous treating doctor.

Determine how long the patient has been taking the drug and why it was originally prescribed.

Check with your state or territory authority to determine whether there is an authority in place.

Some states and territories have local real-time prescription monitoring services. Check those services before prescribing.

View a patient’s My Health Record, as it may hold information on a patient’s prescription history.

Question 40

What are the exceptions to needing an Authority to prescribe a drug of dependence?

(4)

Answer 40

a patient aged 70 years or more and the drug involved is not pethidine

a patient whose life expectancy is less than 12 months if the drug is not pethidine and the prescriber has informed the Minister of the patient’s name, address, date of birth and the nature of the condition for which the drug is prescribed. In these cases, the prescriber must endorse the prescription either “Notified Palliative Care Patient” or “NPCP”

an inpatient in a hospital or correctional institution where the duration of treatment with a drug of dependence does not exceed 14 days

a patient discharged from a hospital following an inpatient stay and the duration of treatment after discharge does not exceed 14 days

Question 41

4 Key steps if a female presents post sexual assault?

Answer 41

1. Referral to a sexual assault referral centre (provide contact details)
2. Offer empiric STI treatment or Screen for sexually transmitted diseases
3. Offer emergency contraception
4. Screen and/or discuss mental health and suicidality.

Can also

Offer PEP for HIV