Medical Records

What Is a Medical Record? In Qld a health record is defined as: – documents, recording the health history, condition and treatment of users of the professional services provided by a person, made in the course of the person's practice of the profession.

Who owns medical records? The doctor if sole practitioner Partners of a private practice The practice itself if it’s corporately owned Hospitals

What goes into medical records? Medical records should include any relevant information pertaining to the diagnosis and treatment of the patient including: – Observations, relevant history, examination, investigations undertaken and results – Patient’s mental state – Clinical opinions – Treatment plan – Medications – Notes on info and advice provided to the patient – Procedures (written consent, details of the procedure, when it was performed, type of anaesthetic used, tissues sent to pathology, outcome)

Can a patient access their medical records? No common law right in private practice Can access your own public hospital record according to federal FOI legislation if: – It is made in writing – Access does no pose a serious risk to the life, physical, mental or psychological health of the patient or another person – Does not breach privacy (eg a spouse cannot obtain their partner’s or if other persons mentioned in the record unduly breaches their privacy)

Who else can access your medical record Generally patient consent is needed to allow transfer information between health service providers (not necessary in emergencies) The HIC, Veterans Affairs and the courts Guardians and substitute decision makers – However, mature minors have the right to confidentiality and parents are denied access – If a child is not competent then either parent has equal right to accessing the medical record Representatives of a deceased person

Medical Records – how long to keep? No Qld legislation AMA Code of ethics recommends – 10 years from last consultation – 10 years after turning 18 for minors

Bioethics Revision N stuff

Autonomy Autonomy means the capacity to realize acts with complete information concerning all of the facts and without internal or external coercion. To achieve this, the patient must have truthful, sufficient, and comprehensive information and must make a voluntary decision. Informed consent is the legal and practical application of the principle of autonomy.

Autonomy Moral Autonomy: a patient’s self-rule must be respected if the person shows capacity eg refusal of treatment Psychological autonomy = capacity – Are they conscious of self – Do they have a belief or value system – Are they acting in their own interests without coercion – Is the decision rational in some sense

Beneficence Promote the wellbeing of others Can “cross the line” when it becomes paternalism: – Strong: my concept of what benefits you overrides your concept even if you have capacity – Weak: my concept of benefit overrides yours if you lack capacity – Persuasion is not paternalism if it in the form of a suggestion and isn’t coercion

Non-malficence Do no harm BUT diagnosis and treatments involve uncertainty and risk. Principles to follow are: – Proportionality: assessing risks and benefits and choosing (and presenting to patients so they can decide) options where the most benefit is obtained with the least risk using clinical judgement – Medical responsibility for the entire process (ie avoidance of blame shifting or “buck passing”) – Setting clear goals and objectives (hospital policies and treatment protocols, standard drug lists)

Non-Malficence & Negligence To prove negligence there must exist – Duty of care – Breach of duty of care – Evidence of harm – Proof that the breach caused the harm

Justice Medical treatment is a scarce resource and its fair allocation is governed by distributive justice: – To each person according to need, regardless of Age Race Religion Sexual preference Social status Mental state (intoxicated, mentally ill, intellectually impaired, aggressive and/or belligerent)

Building Patient Trust What is Empathy? – The intellectual identification with the feelings, thoughts and attitudes of another person Why empathy? – Builds trust between the doctor and patient – Part of treating the “whole” person – Lessens risk of complaints or legal action

Empathy Barriers to empathy – It takes too much time Fewer unsolicited calls and visits by patients – Getting emotionally involved causes loss of control of the situation by the doctor The opposite is generally true – It’s not my job, I’ll delegate to a nurse or psych Causes doctor focus on the physical only Patient perceives the doctor as uncaring or too busy and will filter their responses accordingly

The Therapeutic Language of Empathy Reflection – naming back the emotion Validation – communicating that you understand the reason behind the emotion Support – showing a willingness to remain with the patient while he/she experiences it Partnership – use of “us” and “we” rather than “I” and “you” Respect – praising the patient’s strengths

Quick Empathy Quiz Patient in ICU bed: Doctor, am I having a heart attack? Doctor at bedside: You're understandably worried. I can tell from your lab tests and electrocardiogram that you haven't had a heart attack. Reflection ? Validation ? Reference