Chapter three continuation
(E) Disclosure as a ‘higher’ duty
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- Consent of operation
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(E) Disclosure as a ‘higher’ duty.
The extended of the higher duty may be said to apply when the interest or needs of the public are better served if there is relaxation of the private duty and in some cases where there is a clear legal duty to give information which supersedes the doctrines of confidentiality. More common instances are in the following circumstances:- Notification of infectious diseases by medical doctors to local medical officers of health under Public Health Act (1936)). Notification on cause of death under the births and deaths Act 1836-1926). Notification of industrial poisoning under the Factory and Workshop Act 1901 ( i) to III above represents statutory obligations, whereas although a good cause should be there, is no breach of if it is not. Claims for sickness benefits under the Nation al Insurance Acts Exchange of records between doctors for research purposes. Disclosure to a central body for collective statistics purposes. Disclosure of a central body for collective statistical purposes e.g. hospital activity analysis in the foregoing instances, it is plain that the disclosure is in the public interest. Ownership The records do not belong to the patient if even if fees have been paid. The records belong to the various health institutions which created them. In the case of the government institution, they belong to the government. Case records of private of private intuitions belongs to the institution because they have contributed to creation 0of the records. Retention The Public Records Act stipulates that authorities responsible for public records have a duty to make proper arrangements for selecting those records which should be permanently be preserved for disposal of the rest . There are some records that were spelled out by the Act and they should not be destroyed. Post mortem books Summaries for clinical notes Discharge registers containing diagnosis The rest of the health records in the folder may be destroyed. This should be done six years a after the patient’s last attendance. Each hospital should be able to decide on which records to be destroyed depending on the institutions demands. Security It is the responsibility of each and every institution to ensure that there is security in the storage and handling of health records . This security should be maintained by:- Providing adequate security in the departmental procedures and use of equipment. Instructing lay staff on the confidentiality of health records. Require all lay staff to sign a declaration of secrecy. Health records staff accepting responsibility for disclosure of contents of health records in their possession. Consent of operation It is a regal requirement that a health institution should obtain consent from patient / client before an operation or anesthesia is administered to him in order to safe guard it. It only becomes difficult in the case of children and unconscious patients. In the case of unconscious patients , the surgeon should carry on with the necessary procedures . In case of some body under 16 years, it is necessary for parents or guardian to give a consent .In case of an emergency, consent should not delay the procedure because this could increase the risk. In case the operation is to be done on the child the father is the right person to give consent. But if the father is not accessible, the mother’s consent would be acceptable. If both are not available then, a legal guardian would be obtained. Married women would give consent on their own right just as a single woman. It is wise to obtain a husband’s consent particularly where sterility may follow an operation. For mentally disordered patients , the consent of the nearest relative should be obtained. Medical records Ethics In Greece, Hippocrates known as the “ Father of medicines “ was born about 460BC. He was the first to cast superstition and to practice medicine in scientific principles . He was the auothor of Hippocratic Oath, which is pledged by physicians and other health workers including health records personnel. It states that, “ Whatsoever In my practice or not in my practice , I shall or here amid the lives of men which ought to be noised abroad-as to this I shall keep silent , holding such things unfitting to be spoken.” This is how confidentiality of health records originated and should be maintained until today. Data Protection Act - Subject Access Request Patients can ask to access their record by making a subject access request under Data Protection Act (DPA). It is, therefore important, that records can be efficiently retrieved when required and that appropriate tracking processes are in place, particularly for Clinical Records. Staff should also be aware of their local Data Protection Co-ordinator who must record and monitor any Subject Access Requests (SAR). For further information contact the Trust’s Data Protection Lead.
Access to Deceased Patients Records If the request is for a deceased patient this comes under the Access to Health Records Act (1990) which allows access to a deceased patient’s records in limited circumstances. It allows access to the health records of deceased individuals for their personal representatives and others having a claim on the deceased’s estate. It should be noted that this is subject to certain restrictions e.g. if the patient has left a note to say access should not be given if an application is made after their death. Any requests for access to deceased patient’s records would be covered by the same principles as for a Subject Access Request. Incident Reporting In order to ensure appropriate actions are instigated and any lessons learnt are identified it is important that any incidents relating to records are reported to the appropriate line managers and on the Trust’s Incident Reporting System (Datix). If in doubt about whether to report an incident, raise it with your line manager and discuss. Please remember that something that may seem minor could be part of a chain of other events that could be potentially more serious. For further guidance contact the Trust’s Corporate Risk Manager. Records Storage, Retention, Archiving and Disposal The Data Protection Act requires that for legal and practical reasons records must be stored securely and kept for no longer than legally required. The NHS Records Management Code of Practice (Part 2 – Jan 2009) gives guidance on retention schedules for records both Health and Corporate. The Trust’s Records Retention Archiving and Disposal Policy includes the organisation’s recommended Retention Schedules. For further guidance on how long to retain a record please contact the Records Manager. Local Processes and Local Records Management Leads It is important that local record keeping processes and procedures are documented to ensure consistent good practice within a service, department or team. They will also assist in any investigation to understand why errors or incidents may have occurred. Individual services, departments or teams should have Local Records Managers or Local Records Administrative Leads who can give advice and guidance on the record keeping practices within their areas. Training
Records Management is part of Information Governance and is included in the Trust’s Mandatory Training; refer to the Mandatory Training Policy for further details. The Records Manager will also deliver Record Keeping briefings and workshops as required, which can be adapted to suit a particular service, department or team’s needs. Assignment – make notes on the Kenyan health record policies Download 71.83 Kb. Share with your friends:
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