Good medical records – whether electronic or handwritten – are essential for the continuity of care of your patients. Adequate medical records enable you or somebody else to reconstruct the essential parts of each patient contact without reference to memory. They should therefore be comprehensive enough to allow a colleague to carry on where you left off.
Providing access to medical records is essentially a confidentiality issue; therefore, the starting point is whether or not the patient has consented to disclosure. If not, access should be denied, unless there is some other clear justification for allowing access.
Confidentiality is at the centre of maintaining trust between patients and doctors. As a doctor, you have access to sensitive personal information about patients and you have a legal and ethical duty to keep this information confidential, unless the patient consents to the disclosure, disclosure is required by law or is necessary in the public interest. This factsheet sets out the basic principles of confidentiality.
In this issue we bring you two interesting cases; the first encourages GPs to exercise caution when diagnosing haematuria, and the second highlights how various poor communication channels can have a negative impact on patient care.
The sooner you call MPS about an ethical or legal dilemma, the sooner the matter can be resolved. Professor Carol Seymour, Dr Tom Mosedale, Dr Richard Brittain and Sara Williams explore how and why Collateral-damage foundation doctors get into troubleCollateral-damage foundation doctors get into trouble
The GMC’s latest Good Medical Practice reflects the ever-changing demands of modern healthcare provision, says Dr Rachel Birch, and these two cases illustrate two areas where the GMC has expanded its guidance
Respect for patients’ autonomy is expressed in consent law; to impose care or treatment on people without respecting their wishes and right to self-determination is not only unethical, but illegal.
Doctors may, on occasion, receive a request from a patient’s employer for a medical report to be delivered directly to the HR department, without the patient seeing it. However, before any medical report can be provided, you must be satisfied that the patient has given valid consent to the release of the information. This factsheet looks at the issues surrounding medical reports for employers and other organisations, and offers advice to doctors who are asked to write reports.
As a doctor, you may be asked to give evidence in many different types of forums including criminal or civil courts, Fatal Accident Inquiries and employment or mental health tribunals. This factsheet gives further information about what to expect and how to prepare.
Providing access to medical records is essentially a confidentiality issue; therefore, the starting point is whether or not the patient has consented to disclosure. If not, access should be denied, unless there is some other clear justification for allowing access.
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Read real-life cases of complaints, claims and clinical negligence taken from our archives.
Chosen to give you clear learning points to help you avoid similar situations and reduce your risk, the cases also feature advice from medicolegal experts.
Initiatives to transform the NHS are changing the way GPs and consultants work. At-scale arrangements are increasingly common and clinical contracts are frequently delivered through private organisations and limited companies.
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