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Senior risk adviser Liz Price offers guidance on managing risks in the processing of patient reports

Paperwork pitfalls P

RACTICES receive requests for patient reports from a variety of organisations, including employers, insurance

companies and government agencies – and as such they are part of the daily routine. But a recent analysis of GP cases conducted by MDDUS has identified the extent to which failures in the processing of patient reports can lead to complaints and sometimes claims for negligence. Here I will explore some of the things

that can go wrong when managing requests across the full multidisciplinary process from request to completion.

REQUEST RECEIVED When a request for a patient report arrives at the practice it is important that patient consent is attached. Under the Access to Medical Reports Act (1988), companies must ask a patient’s permission to request a medical report from their doctor. Patients may also choose to see reports before a practice submits it to the company.

Important points to check at this step are: • Has the patient consent form been signed recently (less than six months


prior to the date of request)? The older the consent is, the less valid it becomes (unless of course the request for a report comes as the result of a patient’s death and relates to a life insurance policy). If consent is not recent, the patient should be contacted to confirm that they are happy for the practice to comply with the request.

Does the information requested in the report go beyond the remit of the statement the patient has signed? For example, the information requested may appear to be more extensive than the patient is likely to have anticipated based on the consent given, or the doctor may find information in the medical record that the patient might not realise could be detrimental if disclosed. If in doubt, check with the patient before complying with the request.

It is essential that you only provide

information that the patient has consented to but it is also important to ensure that any additional checks do not cause unnecessary delay in complying with the request. If a

doctor chooses to withhold information which does not fall within the scope of patient consent, ensure that the person(s) requesting the report are informed of this. Some types of report allow for patient

review prior to submission, such as those covered by the Access to Medical Reports Act (e.g. insurance reports). It is important to be aware that there could be a conflict between the interests of the patient, the requirements of a third party and the obligations of a doctor to provide accurate information. Some types of report do not require patient consent, specifically where the doctor is legally obliged to produce the information, but it is good practice to inform the patient, where possible.

WORK-FLOWING THE REQUEST Careful consideration should be given to practice policies around the allocation of a doctor to complete a patient report. Whilst it is important not to overload any particular doctor with such requests, systems which simply use an allocation rota could cause difficulties. An important consideration here is whether any of the doctors know the patient. If a patient is known to a doctor this could assist in completing the form more efficiently

SUMMER 2015  ISSUE 12

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