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YOUR PRACTICE


Do I have to record drug taking in a patient’s notes?


DILEMMA


Three experts advise a GP whose patient has asked him not to note their cannabis smoking in the medical record


A patient doesn’t want me to document a history of cannabis smoking in their notes. How should I respond?


Dr David Mummery Assess the extent of the


cannabis usage Like many decisions of this nature, it depends on the history and context of each individual situation. The Academy of Royal Colleges’


guide to medical record standards1 states that in good clinical recordkeeping there should be ‘a record of lifestyle choices made by the patient which are pertinent to his or her health or social care [including] the patient’s current and previous use of tobacco products, alcohol, recreational drugs’. If a patient mentions a history of cannabis usage, you should ascertain the history and extent of the usage, whether it is ongoing, whether it has caused any medical complications (such as respiratory or mental health problems) and whether there have been any criminal or legal implications (such as arrest or DVLA issues). For example, where an individual has


said to you as their GP that they have tried cannabis on one occasion as a teenager, but they have not had ongoing issues or related problems with it, it would seem reasonable to accede to their request. However, if there is a legal requirement for an accurate drug history, such as a patient agreeing to have their record disclosed as part of the DVLA licence reinstatement process, complying with the ethical standards set by the GMC would require disclosing details of drug use, against the exact letter of the patient’s request. Also, there may be ongoing sequelae of cannabis usage, such as mental health problems. In those situations it would be difficult to justify not mentioning a significant history of cannabis usage in the notes and this should be explained and discussed with the patient. Dr David Mummery is co-vice-chair of Hammersmith and Fulham LMC and a GP in west London


88 February 2016 Pulse


sensitively. I recommend you talk to your colleagues at the practice and seek advice from your medical defence organisation as well as from the BMA, which has a helpful medical ethics team. Dr Saqib Anwar is a GP in Oadby, Leicestershire, and medical secretary at Leicester, Leicestershire and Rutland LMC


Dr Zaid Al-Najjar It may be relevant so should


be recorded Doctors are obliged to document information that is relevant to the patient’s health and ongoing medical care. GMC guidelines state


that ‘clinical records should include relevant clinical findings’.


Dr Saqib Anwar Listen to your patient’s reasoning


In Good Medical Practice, the GMC states that you must treat patients as individuals and respect their dignity, work in partnership with


them and listen to, and respond to, their concerns and preferences. In this case it would be important to understand why the patient does not want you to make this documentation. Perhaps they are fearful of negative consequences. Tackle this head-on to get a better understanding of their perspective. It could be that they are worried about confidentiality issues and so you may be able to reassure them about this. It would also be useful for you to reflect back to the patient your views about the importance of the documentation to help ensure that the best care is given. There are many other factors you should also consider, including how relevant the disclosure is to the medical problem or ailment you are dealing with and the potential impact on the doctor- patient relationship. Whatever your own personal feelings, the GMC would expect you to respect a patient’s right to reach decisions with you about their treatment and care, so this will need to be handled


Reference 1 Academy of Medical Royal Colleges. A Clinician’s Guide to Record Standards – Part 2: Standards for the structure and content of medical records and communications when patients are admitted to hospital. 2008 tinyurl. com/zbjxwsp


The fact that a patient is smoking, and in particular cannabis, may have an impact on their health. It would be appropriate to record this as a relevant clinical finding. Although you might recall this personally, the next doctor to see the patient would be unaware of it. If there are any factual inaccuracies in the patient’s record, the patient has the right to request they be rectified under the Data Protection Act. The most pragmatic way to deal with


this would be to explain politely that medical records are strictly confidential and the information recorded in them assists the doctor to provide safe healthcare and treatment. You should explain the reasons why it may be important for other practitioners to know about the smoking cannabis in the future.


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If the patient is worried about this information being disclosed to others outside the practice, you should reassure them that it will not be disclosed without their explicit consent, and offer to add a note to the medical record stating their discontent that this information has been recorded. The patient should be informed if you think there is a need to disclose such information outside the practice, such as for a referral to secondary care or reports for an external organisation. Dr Zaid Al-Najjar is a medicolegal adviser at the Medical Protection Society and a sessional GP in London


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