Medical Records

1. Medical Records

2. 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.

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

4. 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)

5. 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)

6. 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

7. 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

8. Bioethics Revision N stuff

9. 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.

10. 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

11. 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

12. 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)

13. 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

14. 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)

15. 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

16. 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

17. 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

18. 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