12 record keeping tips
We have made a list of the things to remember when it comes to making and retaining good patient records.
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Record-keeping
Good medical records – whether electronic or handwritten – are essential for the continuity of care of your patients. Adequate medical records enable you or somebody else to reconstruct the essential parts of each patient contact without reference to memory. They should therefore be comprehensive enough to allow a colleague to carry on where you left off.
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NHS Complaints Procedure - Wales
The regulations on NHS complaints in Wales are designed to make complaints handling open and accountable, fair and proportionate, and patient-focused. The emphasis is on resolving concerns in a timely fashion, openly and honestly, and a philosophy of “investigate once, investigate well”.
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Medication
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Duty of candour and reporting concerns
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Consent
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Confidentiality
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Communicating with patients
Patients who are kept informed about their condition and are involved in deciding on the appropriate treatment are more likely to comply with the treatment you suggest, and less likely to complain if things go wrong.
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Chaperones
The medical consultation is a challenge to both doctor and patient, whether in the community or in hospital. The need for more detailed discussions with patients, along with their increasing autonomy and right to make choices in relation to their clinical care and treatment, has affected the traditional role of the doctor-patient relationship. This has made maintaining appropriate professional boundaries in the doctor-patient consultation more challenging, however, the guidance from national and regulatory bodies is clear that it is always the health professional's responsibility to do so.
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Medical Protection comments on the GMC report: State of Medical Education and Practice in the UK 2018
The General Medical Council (GMC) published their State of Medical Education and Practice in the UK 2018 report today. Read the response from Rob Hendry, Medical Director for Medical Protection.
Read moreThe role of receptionists: a legal commentary
A recent Supreme Court decision, Darnley v Croydon Health Services NHS Trust [2018] UKSC 50, has raised questions about the role of non-clinical staff in patient care. The judgment criticised the actions of a receptionist in an Accident and Emergency (A&E) department – Joseph McCaughley, litigation solicitor at Medical Protection, looks at the ramifications of the case
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Group instant messaging in an acute care setting
The NHS has released new guidance to help doctors, nurses and other staff safely use instant messaging during emergencies
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Doctors without legal representation face tougher sanctions from MPTS hearings
Doctors without legal representation face tougher sanctions from Medical Practitioners Tribunal Service hearings.
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Doctors can now prescribe patients medicinal cannabis as of November
But what are the rules surrounding this and what do doctors need to know?
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A touchy subject
Intimate examinations are something that every GP will have to carry out at some point in their career, but it’s important that they are conducted in an appropriate manner, especially if one is required during a home visit. Dr Gabrielle Pendlebury, medicolegal consultant at Medical Protection, gives her advice on how best to manage these situations
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Should you mention the C word when it is probably nothing?
You are concerned there’s a small chance a patient might have cancer. You want to refer them for tests. Do you tell them the possible, albeit unlikely, diagnosis and risk upsetting or scaring them? Or do you try and keep them calm and not mention the C word at all?
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Senior healthcare leaders appointed to lead Medical Protection Society
Online prescription services: what if you disagree?
Online prescription services offer great convenience to patients, but they also come with risks. What do you do if one of your patients has been taking medication prescribed online that you do not think they require? Dr Marika Davies, senior medicolegal adviser at Medical Protection, explores this issue.
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Medical Protection Society calls on Government not to water down the Civil Liability Bill
The House of Commons will debate The Civil Liability Bill for the first time on Tuesday 4th September, which includes reforms that could have more of an impact on the NHS than any other Bill during the past five years. The Medical Protection Society is calling on MPs not to water down proposals to reform how the personal injury discount rate (PIDR) is set and to allow the Bill to proceed quickly.
Read moreArtificial intelligence: who’s liable?
Advancements in medical technology can bring huge benefits for patients and clinicians alike – but new approaches can also mean new risks. Dr Helen Hartley, Head of Underwriting Policy at Medical Protection, looks at where the liability lies for artificial intelligence.
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