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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Removing patients from the practice list
Removing patients from the practice list is an emotive issue and should only be used as a last resort. The reasons for removing a patient from the list can be varied, but it should not be in response to patients lodging a complaint or failing to comply with treatment.
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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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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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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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Managing conflict in general practice
Suzanne Creed, Clinical Risk Education Manager explains how to increase your understanding of conflict and provides some key strategies to deal with it more effectively.
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Top ten tips for managing a redundancy situation
Employment law experts Croner Consulting provide advice on how to manage redundancy within your practice to ensure the rights of employees are respected.
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From the advice line: consent for childhood immunisation
Dr Rachel Birch, medicolegal consultant and editor-in-chief of Practice Matters, shares a recent case where a member sought advice regarding consent for childhood immunisation.
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Treating children and young people safely in general practice
Dr Rachel Birch, medicolegal consultant, provides practical tips to ensure you have systems in place to treat children and young people safely.
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Ask the expert: Is a patient’s son entitled to access his mother’s co...
Ask the expert: Is a patient’s son entitled to access his mother’s confidential information?
Is the patient’s son entitled to access his mother’s confidential information? Where a patient lacks capacity clinicians should consider what action is in the patient’s best interests.
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Ask the expert: Are we obliged to facilitate a request for CCTV foota...
Ask the expert: Are we obliged to facilitate a request for CCTV footage of the practice car park?
Are we obliged to facilitate a request for CCTV footage of the practice car park? You need to consider the confidentiality of other patients. Dr Rachel Birch, medicolegal consultant, answers a member’s query.
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