It sounds a good idea but what about the patient coming for further
treatment without his record. I would be responsible for what I prescribe,
and perhaps I would be considered negligent if I prescribe badly because I
cannot remember and do not have material notes about this patient I have
been treating in the past. Would we need to get him to sign a disclaimer,
and would that be medicolegally acceptable?
We also would hit problems with audits/ quality points etc. unless we did
keep a minimum of relevant information on chronic disease review, or omitted
to include his diagnoses at all on the GP record. At the least we would fail
to be able to specify his notes were summarised, and he had 5yrly BP etc.
Dr Angus Goudie
Kepier Medical Practice
Leyburn Grove, Houghton le Spring
Tyne & Wear, DH4 5EQ
(0191) 5846324
NEW eMAIL: [log in to unmask]
-----Original Message-----
From: Dr Nick Mawby [mailto:[log in to unmask]]
Sent: 19 May 2004 09:57
To: [log in to unmask]
Subject: Re: NCRS security
Fay Wilson wrote:
>From: "Adrian Midgley" <[log in to unmask]>
>Sent: Wednesday, May 19, 2004 9:08 AM
>
>
>
>
>>On Wednesday 19 May 2004 07:33, Laurie Slater wrote:
>>
>>
>>
>>>Security is a prerequisite for confidentiality.
>>>
>>>
>>I suppose it often is, but hippocrates had it adequately well sorted out -
>>don't talk about anything you learn that shouldn't be.
>>
>>IE one may have total confidentiality in the complete absence of any
>>
>>
>secure
>
>
>>systems for communicating by _not_ communicating.
>>
>>
>
>Good to see a consideration of first principles. We are already getting
>patients asking for certain information not to be recorded on the computer
>but the problem is we don't keep paper records. now (maybe we should). The
>problem is that everyone assumes that the record is complete and therefore
>may miss significant matters if they don't ask every time (which sort of
>negates the reason for having records). Maybe we should stop and ask what
is
>the purpose of medical records.
>--
>Fay
>
>
If patients do not want certain info held on computer maybe we should
offer them a patient held record? We could then enter the read code for
patient held record on the computer to alert future clinicians and it
would be up to the patient to bring it with them.
Nick
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