Beneficence - act in the patient’s best interests
Non-maleficence - do no harm
Autonomy - patient has the right to refuse or choose treatment
Justice - concerns the distribution of scarce health resources and the decision of who gets treatment (fairness and equality)
Dignity - the patient has the right to dignity
Honesty - the concept of informed consent has increased in importance since the historical events of the Doctor’s trial at the Nuremberg trials
Commerce vs Care
One can act legally and still not act ethically
Ethics
Ethics and professionalism
Public expect: beneficence, non-maleficence, honesty and integrity, respect for patient autonomy and consent
Why?
Medico-legal
Record of treatment
Clinician
Patient
Other parties
Where?
Case notes
Lab cards
Computer systems
Etc
What?
Level of detail
Important points
Need for brevity vs need for comprehensive records
Space available
Paper records (case notes, lab cards, etc)
Electronic records (e.g. iPAS, PACs, ICE)
Inside?
Personal infirmation
MH
Note of initial discussion, which patient (or reason for attendance)
Charting
Examination notes
Radiographs
Photographs
Study models
Diagnosis, treatment options and discussions with the patient
Treatment offered but declined
Correspondence
Contain?
Patient identifiable information
Up-to-date MH
Treatment information (date, diagnosis, notes, details of treatment carried out, record of findings, record of absences, summary of incidents/episodes)
Missed appointments (offered but declined, late, rebooking)
Phone contacts
Investiagtions and finding
Financial records (fees, payments, unpaid fees)
Correspondence
Consent obtained
Advice
Instructions given
Drugs given (route, dosage, quantity, adverse reactions)
Anything else relevant
How?
Standards
Clearly identify the patient (name, ID number and date)
Contents of medical record should meet the acceptable structure and layout (clinical notes, special investigations correspondence, investigation result, consent forms, other)
Be viewable in chronological order
Be consecutaive
Be accurately dated, timed and signed with the name printed alongside the entry
Be written clearly and legibly, and in such a manner that any justifiable alterations are dated, timed and signed
Be factual, consistent, accurate and easy to read
Be written in black ink
Be written as soon as possible after an event has occurred, providing current information on the care and condition of the patient
Provide clear evidence of the care planned, the decisions made by the most senior healthcare professional, the care delivered and the information shared
Clearly record a change of responsibility of consultant, stating the location and time of transfer of care
The frequency of written entries will be determined by professional judgement dependent on the patient’s condition
Advanced directives, consent and resuscitation status statements must be clear and up to date at all times
Avoid abbreviations, jargon, irrelevant speculations and offensive statements
Be readable when photocopied
Be written with the involvement of the patient
Further Advice
Be written in terms that patients can understand in the event of a patient reading their notes under the Freedom of Information Act
Identify problems that have arisen and the action taken to rectify them
Patient Access to Recorda
Retention of Records
Data Protection Act says ‘record should not be kept longer than necessary’
DoH guidance is ‘no longer than 30 years’
Adults - records should be kept for a minimum of 11 years after treatment completion
Children - retain until 25 years old or for 11 years (whichever is longer)
Electronic Records
Knowt
Note
Studied by 14 people
