CALL LOG


Manager Practice


Call log


These cases are based on actual calls made to MDDUS advisers and are published here to highlight common challenges within practice management. Details have been changed to maintain confidentiality.


DO NOT RESUSCITATE Q A


We are a practice based in Scotland and an elderly but otherwise healthy patient has sent in a letter requesting to formally record that if he should stop breathing he does not wish to have CPR. He wants to complete a DNACPR (Do not Attempt CPR) form to go in his medical records. Is this appropriate?


DNACPR forms reflect a clinical decision, not necessarily a patient’s request. The patient should be advised to complete an advance directive (also called an advance decision in England and Wales). This could be a detailed document setting out the patient’s wishes regarding future treatment, including decisions over the provision of CPR. The patient must have capacity to make such decisions. If an appropriate advance directive is in place then, arguably, a DNACPR form is not


required but may be helpful to indicate to other healthcare professionals that the advance directive should be abided by.


PHOTOCOPY CHARGES Q A


A patient has asked for copies of her full medical records, and claims that under the new GDPR our practice can no longer charge for this. Does this really mean we have to print out all notes for any patient without covering our costs?


Under GDPR you are not allowed to charge patients for access to medical records apart from in exceptional circumstances. The regulations stipulate that a reasonable fee can be charged if a request is unfounded or excessive but these circumstances are likely to be rare: for example, a patient who makes repeated requests for the same information. In general, your patient is correct and you cannot charge for disclosures. The ICO (tinyurl.com/y43yappl) offers advice in relation to GDPR.


FACTUAL ERROR IN NOTES Q


A 19-year-old patient has contacted the practice asking for a correction on her medical records. She applied to join the army but the recruitment office suspended


her application upon reviewing her medical records and noting a “two-year history of back pain”. The patient claims she presented to the doctor twice in a two- month period and the reference to the “two-year history” was after the second consultation. She claims that this is clearly an error and would like to have it corrected. She also requests that the practice forward the amended records to the recruitment office with a covering letter pointing out the error. What would you advise?


A


The practice should first investigate the matter in discussion with the consulting GP. The Data Protection Act (DPA) requires that data controllers ensure that the information they hold is accurate, and it also permits data subjects to request amendments to their records. Such requests usually relate to the correction of factual inaccuracies. In cases where both the doctor and patient agree that the recorded information is factually inaccurate, the record can be amended The original information should be able to be viewed and accompanied by an explanation of why there has been an alteration to the record. Should there be disagreement over the accuracy of an entry, the patient is entitled to include a statement in the record to this effect. In this case, it may boil down to a dispute of fact as to the duration of the symptoms and the practice would need to consider the evidence that is available and make a judgment on how to proceed. Be prepared to explain and justify that decision and the action taken, and ensure this is recorded in the notes.


CONFIDENTIALITY AFTER DEATH Q


The husband of a recently deceased patient has attended the practice requesting access to his wife’s medical records. When asked the purpose and timeframe of the disclosure he admitted that he suspected his wife had terminated a pregnancy a number of years ago and he wants to check. He has now provided evidence that he is the executor of his wife’s estate. Should we comply with this request?


04 AUTUMN 2019  ISSUE 21


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