Disclosures and Consents
Keeping good records is an important part of health care, and it should be done with care and respect (Grace, 2017). The records must be accurate and thorough so that they can be used to track a patient’s health and come up with effective ways to treat them. Legally, keeping patients’ health records helps to protect practitioners when they need to defend themselves in court for something they did. Health law courts presume that any health action that is not documented was never taken.
Health records are also important in determining whether services have been improved to address the health concerns that have been recorded. The Code of Professional Conduct says that health professionals must make sure that the information they record matches the treatment, care plan, and delivery (Grace, 2017). But the information should be written down while the patient is there and with his or her permission.
Adopting a computer-based patient record is one way to improve recording and reporting. When one practitioner gets information about a patient, it is sent electronically to other practitioners who will take care of the patient (Grace, 2017). It will also be important to make sure that practitioners don’t have too many patients. If a practitioner has a hundred cases to deal with, he or she might forget to write down the details of the patients or write them wrong because they are in a hurry.
The patient must provide consent for the information to be disclosed to a third party. To make sure that there is disclosure and consent, practitioners should tell patients why and what information will be shared (Grace, 2017). The consent must be in writing and filed so that there is proof that the patient agreed to the information being shared with a third party. But implied consent is assumed if the medical exam was done because someone else asked for it.
References
P. J. Grace (Ed.). (2017). Advanced practice nursing ethics and professional responsibility Jones & Bartlett Education
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