The patients right of access

The Health Records Act of 1990 gives patients the right to see and rcccive a copy of their casenotes. It is unprofessional and potentially distressing to patients if judgemental or flippant comments are recorded. This should be borne in mind when details of a patient's behaviour, personality and relationships with other people are being described. Patients can be denied access to any part of their casenotes if it is considered that this would be likely to cause serious harm to their physical or mental health or damaging to any other individual. This may be important if a named third party, or somebody unnamed but who could be identified, has provided sensitive information, for example of sexual abuse. It is necessary to record such information on separate sheets of paper duly signed and dated by the clinician.

The system for case recording is widely accepted, and indeed many hospital units now supply printed proformas as aides-memoire. At first, case records can seem baffling because of the extent to which abbreviations are used. Because of pressure of time in clinical practice, these are acceptable but should not be overused. Those which are widely recognised have been included in the texl. A particular feature is the use of the prefix to signify "no', for example "tenderness, or "headache. Obscure acronyms should be avoided.

It is not necessary to record all the details of She history and examination in every patient. Sonic negative findings may be relevant but many can be safely omitted. It becomes easier to judge what does and does not need to be included with increasing experience. For instance, in a patient presenting with breathlessness, the negative details of the respiratory enquiry should be included while the negative responses to the gastrointestinal enquiry could be condensed to 'none" or "nil'.

Drawings may be helpful, particularly of the abdomen (see Figs 5.9 and 5.10, p. 164) to illustrate the position of tenderness, masses or scars. They are also useful for recording the site and size of superficial injuries or ulcers. A sample case record is shown on the following pages with explanatory notes alongside each section in turn.

TABLE 9.1 Purpose of the case record

Documentation of history and examination findings

Sharing of information with medical colleagues and other health

professionals

a

Record of results of investigations

Documentation of assessments by other health professionals, e.g.

dietitians, therapists

Record of decisions made regarding patient investigation and

management

Record ol patient's progress

Documentation of information and education provided to patient and

patient's relatives

Record of correspondence regarding patient's management

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