Manager Practice
Some issues, such as a child protection
order, can be noted on the medical file along with any relevant medical information but detailed files should not be kept in the clinical records. Remember that clinical records will follow a patient throughout their life.
DATA PROTECTION RISKS Another risk in recording non-clinical patient details comes under the Data Protection Act 1998. This Act applies UK-wide to all data about identifiable, living individuals. In the context of medical and dental practice it covers patient records held on computer or in paper files, and extends to handwritten notes and imaging. Under the Act a patient has a right of access to see personal information and to have it corrected if it is wrong. The Act introduces eight data protection principles that set out the standards for handling infor- mation. Data must be:
• •
fairly and lawfully processed processed for limited purposes
• adequate, relevant and not excessive •
accurate
• not kept for longer than is necessary •
•
processed in line with the data subject’s rights secure
• not transferred to countries outside the EU without adequate protection.
Anything recorded, no matter where it is
stored, is potentially recoverable under the Data Protection Act so it should be made very clear to practice staff that relevant emails,
text messages or other notes may someday be seen by a subject patient or carer and pos- sibly challenged. Notes on patient behaviour should be neutral and non-judgemental – a simple statement of the facts: For example: “The patient clenched his fist and called me a …”
“
of potentially violent individuals is in place in some NHS service providers. Markers can be applied regardless of whether the act was in- tentional or not so as to “reduce possible risks to NHS staff by enabling them to consider and implement measures for their protection.” Practices should be aware how their own
IT IS ESSENTIAL THAT PRACTICES UNDERSTAND HOW THEIR IT SYSTEMS OPERATE
” Not every heated confrontation need be
recorded. The RCGP offers guidance on what is considered unacceptable behaviour, such as discriminatory abuse, sexual or racial har- assment, physical or verbal abuse including threats and gestures, and violence.
HEALTH AND SAFETY CONSIDERATIONS
In the context of aggression and violence all practices have a legal duty of care not only to staff and other patients but all healthcare professionals who may come in contact with an abusive patient. Most practices will oper- ate a zero tolerance policy towards violence against staff with all incidents followed by a formal warning and possible removal from the practice list. The RCGP provide clear guidance on removal of patients from a practice list and it is advised that wherever possible this guid- ance should be followed. A formal system for placing violence markers on the electronic or paper records
local commissioning bodies or health authori- ties identify violent patients but should also be aware that any such schemes must be compliant with the Data Protection Act on issues of fairness. This will mean informing the patient that they have been identified as being potentially violent. There are also obligations to staff under health and safety regulations. No less than five pieces of legislation are relevant to protect- ing employees from violence at work, includ- ing The Health and Safety at Work Act 1974. It is important that serious incidents of
patient aggression are logged and dealt with but the trick is to ensure that doing so brings no additional medico-legal risks for practices.
Jim Killgore, associate editor, Practice Manager, in discussion with Liz Price, training and consultancy manager, Alan
Frame, risk adviser, and Dr Anthea Martin, senior medical adviser at MDDUS
WWW.MDDUS.COM
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