Health Records in Court / Edition 1

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This book is an essential tool for all healthcare professionals. An understanding of the law and the way in which it impacts upon roles, responsibilities and care is a vital component in everyday healthcare. Written in a clear and concise style, Health Records in Court provides practical legal advice by highlighting real-life healthcare case studies and workplace examples. It offers much-needed, clearly explained guidance for navigating the complexities and intricacies of medico-legal processes, practices and obligations - vital for every health professional who creates, adds to or maintains health records.

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Product Details

  • ISBN-13: 9781846192227
  • Publisher: Radcliffe Publishing
  • Publication date: 10/1/2009
  • Edition number: 1
  • Pages: 178
  • Product dimensions: 6.70 (w) x 9.60 (h) x 0.60 (d)

Meet the Author

Jane Lynch
Jane Lynch

Jane Lynch grew up on the South Side of Chicago and currently lives in Los Angeles. She married Dr. Lara Embry in 2010, and was lucky enough to get two daughters in the deal.

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Table of Contents

Foreword ix

Preface x

About the author xii

Acknowledgements xiii

1 Introduction to health records 1

2 Health records and the law 5

The court system 5

Sources of law 5

Guidelines and codes of practice 9

Court structure 10

Civil law 11

Negligence 11

Criminal law 14

3 Accountability 19

Accountability in a legal context 21

The four areas of accountability 22

Legal and professional obligations 30

4 Will the records stand up to legal scrutiny? 33

Case study 33

5 Good practice for health records 43

The purpose of health records 47

Record keeping is a chore 49

What constitutes the health records and legal documents? 50

Who should write the records? 52

When should the records be written? 53

How much should be written? 55

What should be written? 56

What to include 57

What to omit 58

Don't keep it in your head 58

Health records should include... 59

6 The detail 63

Inadequate detail 63

The rationale 64

Clarity of detail 65

Clear and unambiguous 68

Care and condition 68

Advice given 69

Advice and consent 69

Action 71

Negative findings 71

Frequency of the entries 72

Spelling and grammar 72

Missing information 73

Patient's details 73

7 How do we record? 75

Protocols and guidelines 75

Aggression 76

Failure by the patient to comply 76

Third party information 76

Telephone advice 77

Complaint 79

Recording consent issues 81

Understanding, language and interpreters 84

Dates and times 84

Authenticate 88

Designated place for recording allergies 90

Standard forms and tick boxes 90

Legibility 91

8 Fact, assumption, professional opinion 93

Fact and assumption 93

Professional opinion 96

9Amending the records 99

Amending mental health records 99

10 What to leave out 103

Jargon 103

Routine and meaningless entries 103

Gratuitous entries 105

Subjective comments 106

Abbreviations 106

Arrows and dashes 108

Do not squeeze information in 108

Do not leave gaps 108

11 Common errors in the records 111

Transmitting and receiving information 113

Duplication of health records 113

12 Sharing information 117

Inter-professional access to records 117

Communication between healthcare professionals 118

Confidential information 121

Records used for research and teaching 123

Records used for clinical audit 123

13 Access to health records by the patient 125

Patient's right of access to health records 125

Withholding information 126

Children's records 127

Copying letters to GPs and patients 128

14 Systems of record keeping 135

Supplementary records 137

Electronic records 138

15 Further considerations 143

Infection control and the records 143

Mental health records 143

Midwifery records 145

Social care records 146

16 Who owns the health records? 149

Patient-held records 149

Supplementary records 150

Storage of health records 150

17 Health records used to prepare witness statements and reports 155

A statement, report or expert report? 155

18 Health records used as evidence 159

Will your records stand up to legal scrutiny? 159

Untrue or false entries 161

Missing records 162

What is the court looking for? 162

Lack of professionalism 163

19 Defensive writing 165

20 Assessment criteria for health records 167

Glossary 169

Index 175

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