Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2720_Библиотеки_им_академика_М_И_Перельмана
.pdf
44
https://t.me/med1917
44
CHAPTER2 Practicemanagement
Patientrecords
General principles Patient records should be factual, consistent,
and accurate. Ensure a logical sequence; be clear, unambiguous, and
concise. Use standard coding techniques if using an electronic record—
standard templates may help. Wherever possible, write notes openly
while patients/ carers are present in terms they can understand. Ensure
that the record is correctly dated, timed, and identiable to the person
creating the record. Record:
• Information on which you have based your decisions Presenting
problems; past/ family history; examination ndings and test results
• Your impression of the situation How you see the problem— may
include diagnosis, dierential diagnosis, prognosis
• Plan of action Negotiated between patient and doctor— may include
tests requested, prescriptions given, referrals made
• Information shared and advice given Relevant worries/ concerns
voiced by the patient; information/ advice provided to the patient—
especially safety netting advice and review/ follow- up arrangements
• Other essential information e.g. correspondence to/ from other
agencies; if consent for treatment/ examination (E p. 48) was given
0 Do not include Abbreviations (especially unconventional ones);
jargon; or personal views about behaviour or temperament unless they
have a bearing on the management of the patient.
Condentiality E p. 46 Electronic patient records E p. 37
Summary Care Record (SCR) Electronic medical notes summary
extracted from GP IT systems that can be viewed by healthcare sta in
other NHS settings. At a minimum, the SCR holds information about current medication, and allergies/ adverse reactions to medicines. The patient
can also choose to include additional information, e.g. long- term conditions,
signicant medical history, or specic communication needs.
Shared electronic GP records NHS plans for healthcare organiza-
tions to work more closely together often depend on sharing patient information, including GP records. As a result, local data sharing arrangements
are in place throughout the UK. However, the registered GP practice legally
remains the ‘data controller’ for the record.
• Be clear on the sharing arrangements that you are part of
• Communicate and explain data sharing arrangements to patients; gain
explicit consent for data sharing where possible and record any objections.
Some GP systems allow patients to view who has looked at their data
• Act on any indications of illegitimate record access
Patient Online Allows patients online access to practice systems and their
electronic GP notes to book/ cancel appointments, order repeat prescriptions,
and view their GP record including test results and hospital correspondence.
Amending records Rectify errors of fact or judgement. Any alterations
or additions should be dated, timed, and signed in such a way that the original entry can still be seen. Patients may request correction of information they believe is incorrect— you must record the patient’s view. Highlight
amendments and reasons for them.
https://t.me/med1917
PATIENTRECORDS
Subject access requests (SARs) Under the Data Protection Act
1998 and 2018, patients have a right of access to health records which:
• Are about them and from which they can be identied
• Consist of information relating to their health or condition
• Have been made in connection with their care
Requests should usually be written (paper or electronic). Medium in which
records are supplied can be agreed between the patient and the practice
and may be paper (photocopy, computer printout), electronic (e.g. USB
stick), or by facilitating patient access to Patient Online.
Since May 2018, practices cannot charge a fee for this service, although may
charge for repeat requests. The entire record should be provided within
1mo of the SAR unless the patient agrees to limit the request (e.g. to electronic records only, or records made since a dened date).
Who can seek access?
• Any competent person may seek access to their own health records,
including competent children (E p. 46)
• Any person with parental responsibility may apply for access to records
of a child (<18y, or <16y in Scotland). Where >1 person has parental
responsibility, each may apply independently without consent of the
other parent
• Athird party authorized by a competent person may seek access to that
person’s records (e.g. solicitor or insurance company), but proof of
permission from the patient must be provided. If there is doubt, contact
the patient to verify consent has been given
Mentally incapacitated adults Where access is sought and the individual lacks
capacity to give permission, decisions must be based on the person’s best
interests, taking into account the views of the person’s representative(s)
and the individual’s expressed wishes and values— E p. 46.
Access todead patients’ recordsE p. 46
0 If unsure, take advice from the BMA or your defence organization.
Security of records Do not leave records (electronic or manual) un-
attended in easily accessible areas. When not in use, store paper les and portable electronic equipment locked up. Query the status of strangers. Highlight
concerns to the practice manager. Do not reveal how security systems work.
• Manual records Store les closed and in logical order. Use a tracking system
to monitor whereabouts of les, and return les as quickly as possible
• Electronic records Do not leave terminals unattended and logged in.
Do not share logins or reveal passwords to others. Change passwords
regularly, and avoid using short or obvious ones. Keep smart- cards
securely. Always clear the screen of a previous patient’s information
before seeing another. Use a password- protected screen saver to
prevent casual viewing of patient information by others
Further information
BMA M www.bma.org.uk
• Access to health records:guidance for health professionals in the UK
• Medical records access:GDPR changes to Subject Access Requests and
fees from 25 May 2018
GMC Guidance on good practice— condentiality. M www.gmc- uk.org
45
ALGRAWANY
46
https://t.me/med1917
46
CHAPTER2 Practicemanagement
Confidentiality
Respect for condentiality is also an essential requirement for the preservation of trust between patient and doctor. Failure to comply with standards can lead to disciplinary proceedings and even restriction/ cessation of
practice.
Caldicott Principles fordisclosure ofpatientinformation
• Justify the purpose Patients may agree to identiable information
about themselves being released to specic individuals for known
purposes. Implied consent applies when patients are aware that
personal information may be shared and of their right to refuse but
make no objection. Patients must have a realistic opportunity to
refuse— and if they do refuse, clearly document that and respect their
decision
• Do not use patient identiable information unless it is absolutely
necessary It is not necessary to seek consent to use anonymous
information. If in doubt, seek advice from the BMA or your defence
organization. Health information used for secondary purposes, e.g.
planning, teaching, audit, should— when possible— be anonymous
• Use the minimum patient identiable information
• Access to patient- identiable information should be on a strict
‘need- to- know basis’
• Everyone should be aware of their responsibilities
• Understand and comply with the law
Specialcircumstances
Children (<16y) Disclosure can be authorized by a person with parental responsibility. Young people, mature enough to understand the implications,
can make their own decisions and have a right to refuse parental access to
their health record.
Mentally incapacitated adults Assessment of capacity to consent to information disclosure is time- and decision- specic. A mentally incapacitated
adult can consent to information disclosure if the person is able to:
• Understand the concept of authorizing/ prohibiting sharing of
information
• Retain that information long enough to make a decision
• Weigh up the implications of disclosure or non- disclosure
• Communicate a decision
Otherwise, decisions must be based on an evaluation of the person’s best
interests, taking into account the views of the patient’s representative(s)
and reecting the individual’s expressed wishes and values.
0 Except in Scotland, parents are able to consent for mentally incapacitated 16– 17y olds.
The deceased Legislation covering records made since 1 November 1991
permits limited disclosure in order to satisfy a claim arising from death.
Where there is no claim, there is no legal right of access to information.
Breaching condentiality Only breach condentiality in exceptional cases
and with appropriate justication. This includes discussing a patient with
https://t.me/med1917
CONFIDENTIALITY
another health professional not involved currently with that patient’s care.
Wider disclosure to people loosely associated with care (e.g. support sta
in residential care settings) requires patient consent.
Situations where breach ofcondentiality may bejustied
• Emergencies Where necessary, to prevent or lessen a serious and
imminent threat to the life or health of the individual concerned or
another person (unless previously forbidden by the patient)
• Statutory requirement Ask under which legislation it is sought— check
the legislation before disclosing if unsure
• The public interest What is in the public interest is not dened. The
BMA has produced guidance
• Public health Reporting notiable diseases (statutory duty)
• Required by court or tribunal
• Adverse drug reactions Routine reporting to the Medicines and
Healthcare products Regulatory Agency (E p. 120)
• Complaints As part of GMC performance procedures involving doctors
Legalconsiderations
• Human Rights Act (1998) Establishes a right to ‘respect for private
and family life’ and creates a general requirement to protect the
privacy of individuals and preserve condentiality of their health
records. Compliance with the Data Protection Act and common law of
condentiality should satisfy requirements
• Common law of condentiality Built up from case law where practice
has been established by individual judgements. The key principle is that
information conded should not be used or disclosed further, except
as originally understood by the conder, or with their subsequent
permission, except in exceptional circumstances (E p. 46)
• Administrative law The extent the NHS can access condential
information to perform its functions is set down in statutes
• Health and Social Care Act (2001) Allows for certain exceptions to
condentiality laws to be made, e.g. for use in cancer registries
• Freedom of Information Act (2000) Applies to all NHS bodies,
including GP practices. Practices are required to produce a publication
scheme detailing all information routinely published by the practice. In
addition, members of the public can make written requests to see any
information recorded by the practice in any format. These rights are
restricted by certain exemptions, e.g. personal data
• Data Protection Act (1998 and 2018) Imposes constraints on
processing of personal information. Also requires personal data to be
protected against unauthorized/ unlawful processing and accidental loss,
destruction, or damage. Also applies to personnel records
• European General Data Protection Regulation (GDPR) (2018)
European legislation strengthening individual rights to control of data, to
be informed of any data breaches and creating a right to ‘erasure’
Further information
BMA Condentiality and people under 16. M www.bma.org.uk
GMC Guidance on good practice— condentiality. M www.gmc- uk.org
Information Commissioner’s Oce Data protection. M www.ico.gov.uk
47
ALGRAWANY
48
https://t.me/med1917
48
CHAPTER2 Practicemanagement
Consent
Consent Implies willingness of a patient to undergo examination, inves-
tigation, or treatment (collectively termed ‘procedure’ in this section). It
may be expressed (i.e. specically says yes or no/ signs a consent form) or
implied (i.e. complies with the procedure without ever specically agreeing
to it— use with care). For consent to be valid, patients:
• Must be competent to make the decision
• Have received sucient information to take it
• Not be acting under duress
Under ‘common law’, touching a patient without valid consent may constitute the civil or criminal oence of battery, and if the patient suers harm
as a result of treatment, lack of consent may be a factor in any negligence
claim. Never exceed the scope of the authority given by a patient, except
in an emergency.
If you are the doctor carrying out a procedure, it is your responsibility to
discuss it with the patient and seek consent. The task may be delegated, but
the responsibility remains yours.
Information toinclude
• Reasons why you want to perform the procedure
• Nature, purpose, and side eects (common and serious) of proposed
procedure
• Name of the doctor with overall responsibility
• Whether students or other ‘trainees’ will be involved
• Whether part of a research programme or outside usual procedure
• Reminder that patients have a right to seek a second opinion and/ or
can change their minds about a decision at any time
And fortherapeutic procedures/ treatments
• Details of diagnosis and prognosis (including uncertainties)
• Management options— including the option not to treat and other
options that you cannot oer— and, for each option, an estimation of
likely risks, benets, and probability of success
• Details of follow- up in order to monitor progress or side eects
0 Document if a patient doesn’t want to be fully informed before
consenting.
Written consent It is good practice to seek written consent if:
• The procedure is complex or involves signicant risks (‘risk’ means any
adverse outcome, including complications and side eects)
• The procedure involves general/ regional anaesthesia or sedation
• Providing clinical care is not the primary purpose of the procedure
• It has consequences for employment, social, or personal life of the
patient
• The procedure is part of a project or programme of approved research
Establishing capacity tomake decisions E p. 96
https://t.me/med1917
CONSENT
Mentally incapacitated adults The Mental Capacity Act (2005), and
equivalents in Scotland and Northern Ireland, enable patients’ advocates
(usually friends, relatives, or carers) or suitable professionals (e.g. doctors,
social workers) to act in patients’ best interests on their behalf. This includes
provision of medical care. Before acting:
• Take all factors aecting the decision into consideration
• Involve the patient with the decision- making as far as possible
• Take the patient’s previous known wishes into consideration
• Consult everyone else involved with the patient’s care/ welfare
In situations in which there is disagreement about the patient’s best interests, the decision can be referred to the Court of Protection.
Advance statements Ep. 97
Children (<16y) A competent child is able to understand the nature,
purpose, and possible consequences of a proposed procedure as well as
the consequences of not undergoing that procedure. This is termed ‘Gillick
competence’ after the court case in which the principle was established
(Gillick v West Norfolk and Wisbech AHA [1986] AC 122).
A competent child may consent to treatment. However, if treatment is refused, a parent or court may authorize procedures in the child’s best interests.1 Where a child is not judged competent, only a person with parental
responsibility may authorize/ refuse investigations or treatment. If in doubt,
seek legal advice.
Emergencies When consent cannot be obtained, you may provide
medical treatment, provided it is limited to what is immediately necessary
to save life or avoid signicant deterioration in the patient’s health. Respect
the terms of any advance statement/ living will you are aware of.
Further information
GMC (2008, under review) Consent:patients and doctors making decisions together. M www.gmc- uk.org/ ethical- guidance/ ethical- guidance- fordoctors/ consent
GMC (2018) 0– 18years:guidance for all doctors. M www.gmc- uk.org/
ethical- guidance/ ethical- guidance- for- doctors/ 0- 18- years
Oce of the Public Guardian Health and social care workers:Mental
Capacity Act decisions. M www.gov.uk/ government/ publications/
health- and- social- care- workers- mental- capacity- act- decisions
49
1 Note:in Scotland, parents do not have this power to overrule a competent child’s decision.
ALGRAWANY
50
https://t.me/med1917
50
CHAPTER2 Practicemanagement
Complaints
Sadly, complaints are a fact of life for most GPs. The most constructive
and least stressful approach is to view them as a learning experience and a
chance to improve practice risk management strategy. Always contact your
local LMC ± defence organization if you are directly implicated in a complaint. Patients who complain generally want:
• Their complaint to be heard and investigated promptly
• Their complaint to be handled eciently and sympathetically
• To receive a genuine apology if mistakes have occurred
• To be assured that steps will be taken to prevent a recurrence
NHS complaints procedure for general practice Figure 2.1
Patient/patient’s representative wants to make a
complaint about a GP or practice service
Step 1: Local resolution
PCO
Person receiving the complaint makes a note of:
•
date received, contact details of the person making
the complaint, and nature of the complaint
•
Complaints manager (usually practice manager)
acknowledges the complaint within 48h and advises
the complainant of right to conciliation ( p. 51)
Complaints manager investigates the complaint,
•
consulting all involved
• Complaints manager makes a written summary of
the nature of the complaint, investigation ndings ±
apology ± actions taken to remedy the situation/
prevent future recurrences. This must be completed
<25d after the original date of the complaint
p. 25
Practice
Complaint resolved?
Step 2: Ombudsman
Figure2.1 The NHS complaints procedure for general practice
NO
Time limits forcomplaints NHS complaints can only be accepted:
• <1y after the incident which is the subject of the complaint, or
• <1y after the date at which the complainant became aware of the matter
https://t.me/med1917
COMPLAINTS
After that time, complaints can only be accepted if there is good reason for
delay and it is possible to eectively investigate.
A 3y time limit after the incident (or after the date upon which the claimant
became aware that the incident might have caused harm) is placed on civil
clinical negligence cases, except for children who may claim until their 21st
birthday.
Conciliation Is a way of dealing with complaints that helps to avoid ad-
versarial situations. Either party can ask the local PCO for conciliation, but
both parties must agree to it taking place. By bringing the two sides together
with a neutral conciliator, it aims to:
• Explain and clarify matters for both parties
• Ensure both parties are really listening to each other
• Ensure the process is unthreatening and helpful
Records ofcomplaints A le on the complaint, including a copy of
all correspondence, should be kept separate from clinical records of the
patient and, if the patient leaves the practice, should not be sent on with
the clinical notes.
Private sector Most private sector healthcare providers have their own
complaints resolution procedures. Patients should contact the organization
concerned for details.
Disciplinary procedures There is no direct connection between com-
plaints procedures and disciplinary action. If a complaints procedure reveals
information indicating the need for disciplinary action, it is the responsibility
of the PCO to act. If they decide there has been a breach of the terms of
service, the PCO can x a penalty, if appropriate.
Further information
Risk management E p. 31
BMA M www.bma.org.uk
Medical defence organizations
51
ALGRAWANY
52
https://t.me/med1917
52
CHAPTER2 Practicemanagement
Qualityimprovement
Quality improvement (QI) comprises a set of values and tools for proactively setting goals and planning, implementing, and measuring change in
order to improve patient care. Aculture of quality should exist throughout
all healthcare organizations, and every team member should be involved in
delivering and improving quality.
Steps toquality improvement Establish a quality improvement cul-
ture. Within practices there should be continuous review and appraisal of
procedures and standards— RAID:
• Review— gather all stakeholders together to look at a topic
• Agree— a strategy to take forward. All objectives should be SMARTS
(specic, measurable, achievable, relevant, time limited, and sustainable)
• Intervene— make changes decided upon
• Demonstrate— the eect of changes through audit (E p. 54), patient
satisfaction questionnaires, prescribing data, etc.
Methods ofidentifying topics forQI Tools include:
• Review of new guidelines/ clinical pathways for compliance
• ‘Always events’— feasible care processes that patients identify should always
happen when they interact with GP practices, e.g. timely appointments
• ‘Never events’ (Box 2.2)— a validated list of events known to cause
severe harm that are completely preventable— could any of these
events happen in your practice? How might you minimize risk?
• General Practice Safety Checklist (MoRRIS checklist)
• Trigger tool— review a sample of records of high- risk patients (e.g.
patients who are designated ‘frail’) for undetected incidents
• External peer review of practice procedures and care pathways
• Signicant event reviews— E p. 54
• Criterion- based audit— E p. 54
Risk management Ep. 31
Clinical governance Dened as ‘a framework through which organ-
izations are accountable for continuously improving the quality of their
services and safeguarding high standards of care by creating an environment
in which excellence in clinical care will ourish’.
Essential elements of clinical governance Figure 2.2
Care Quality Commission (CQC) The Health and Social Care
Act 2008 required any individual, partnership, or organization providing
healthcare services in the UK to register with CQC as a service provider.
Monitoring After registration, CQC regularly inspects practices to ensure
that they meet essential standards. After inspection, each practice is rated
according to its performance against CQC criteria and awarded an overall
rating of ‘Outstanding’, ‘Good’, or ‘Inadequate’.
0 Practices deemed inadequate by CQC usually remain registered but
must ensure that they take steps to manage any risks posed by noncompliance, and must submit an action plan to explain the steps that will be
taken to meet compliance with a target date for achievement.
Concerns about GP performance Ep. 11
https://t.me/med1917
QUALITYIMPROVEMENT
Box 2.2 ‘Never events’ forQI
• Drug prescribed to a patient where it is recorded in the patient’s
notes as having previously caused a severe adverse reaction
• Planned referral of a patient with suspected cancer is not sent
• Prescribing a teratogenic drug to a patient known to be pregnant
(unless initiated by a specialist)
• Emergency transport is not discussed or arranged when admitting a
patient as an emergency
• Abnormal investigation result is received but not clinician reviewed
• Aspirin is prescribed for a <12y- old patient (unless recommended by
a specialist for a specic clinical condition, e.g. Kawasaki’s disease)
• Systemic oestrogen- only hormone replacement therapy is prescribed
for a patient with an intact uterus
• Methotrexate is prescribed daily rather than weekly (unless initiated
by a specialist for a specic clinical condition, e.g. leukaemia)
• Needle- stick injury is caused by a failure to dispose of ‘sharps’ in
compliance with national guidance and regulations
• Adrenaline (or equivalent) is not available when clinically indicated for
a medical emergency in the practice or GP home visit
Reproduced from de Wet etal. Developing a preliminary 'never event' list for general practice
using consensus- building methods. BJGP, 64 620), e159– e167, 2014. Copyright © British Journal
of General Practice 2014. Distributed under the terms of the Creative Commons Attribution
3.0 Unported (CC BY 3.0) http:// creativecommons.org/ licenses/ by/ 3.0/
p. 25)
p. 33)
CQC
Risk avoidance
•
Risk management
•Clear protocols
• Safe environment
• Staff training
Audit Education/training Sta
Regular review of
practice against quality
standards—
p. 54
Clear standards of service
Clinical governance
Infrastructure Clinical eectiveness
• Access to evidence
• Time
• Training strategies
•IT support
• Effective appraisal
• Performance
feedback
• Targeted education•Teamwork
• Sharing good practice
• Significant event audit
•Evidence-based
medicine
•Leadership
•Common goals
•Communication
53
p. 11)
p. 56)
Figure2.2 How does clinical governance t with other QI initiatives?
Further information
Bowie P, etal. (2015) Participatory design of a preliminary safety checklist
for general practice. BJGP 65(634):e330– 43.
Care Quality Commission M www.cqc.org.uk
de Wet C, etal. (2014) Developing a preliminary ‘never event’ list for
general practice using consensus- building methods. BJGP 64(620):e159– 67.
ALGRAWANY
Monitored
standards
Соседние файлы в папке Библиотека им академика М.И. Перельмана