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Performance Matters- sharing medical records

Performance Matters- sharing medical records

The LMC is regularly involved in representing and supporting doctors who have been identified as having "performance" issues. The LMC has identified a number of themes which recur, and this regular feature from our newsletter will highlight these, so that our members can avoid these pitfalls.

 

In a recent case a patient was identified as being end of life by his GP practice, and was started on the End of Life pathway.  The practice discussed the patient’s case at their two-monthly palliative care meeting and the community nursing team and St Barnabas were informed of the patient’s condition.  

 

The patient deteriorated and later required input from the community nursing team and St Barnabas.  When this happened in the out of hours period, the community teams were unable to access the patient’s record, or see information in the Care Portal, due to the “consent to share” being set as “explicit dissent to share”.  This meant that the community teams had to work without adequate information about the patient.

 

The patient’s family later complained about the service provided, and that they and the patient had never dissented to their records being open, and they could not remember being asked.

 

When the complaint was reviewed, a number of learning points were discussed:

  • Where a patient is identified as frail or end of life it is in their best interests for all health and care services to have access to their records, so this should be reviewed
  • Use of the Electronic Palliative Care Coordinating System (EPaCCS) template in clinical systems prompts for consent to gained to share records, and allows for consistent communication between care providers
  • The practice had set all its patients to explicit dissent to share, this is not appropriate
  • Caldicott Principle 7 states “The duty to share information can be as important as the duty to protect patient confidentiality.  Health and social care professionals should have the confidence to share confidential information in the best interests of patients.”  Thus if we feel that it is in the patient’s best interest we can share their data even if they have dissented for us to do so.

Following this case the LMC advises practices to:

  • Review their frailty and End of Life registers and ensure that the appropriate sharing options have been enabled for the patients
  • Use the EPaCCS templates for End of Life patient