HEALTH RECORDS IN COURT
2009192 pages Paperback
ISBN-10 1 84619 222 6
ISBN-13 9781846192227
Jane Lynch, Negligence Lawyer and Fellow, Royal Society of Medicine
Foreword by Peter Carter, General Secretary, Royal College of Nursing
Description
MEDICO-LEGAL ESSENTIALS SERIES
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.
For more information on other titles in this series please click here
‘This book is both timely and welcome. Well written, clear and concise this book provides useful and practical advice by highlighting real-life case studies and workplace examples. It provides a much-needed guide for navigating the complexities and intricacies of medico-legal processes, practices and obligations.’
Peter Carter, in his Foreword
Review Quotes 'Most health records are in no fit state to be taken to court. They are the weakest link in any episode of care and the subject deserves a higher status. This book represents good value for money if you use it as intended, which is as a guide to keeping yourself out of very deep water and it has the advantage of being written in a language that is accessible to the entire dental team.' THE GDP
'Brief and to the point, and delivers a number of key messages to practitioners about this dual use of their records. Useful as a reminder for pressurised health professionals on the treatment (and potentially defensive) value of systematic record-keeping.' HEALTHCARE COUNSELLING AND PSYCHOTHERAPY JOURNAL
 Introduction to health records Legal and professional obligations The court system Sources of law; statute and common law Guidelines and codes of practice Court system Civil law; negligence Criminal law Accountability Four areas of accountability Legal and professional obligations Will the records stand up to legal scrutiny Case study Good practice for health care records The purpose of health records Record keeping is a chore What constitutes a health record and a legal document Who should write the records When should the records be written How much should you write What should you write What to include What to leave out Don’t keep it in your head The detail Inadequate detail The rationale Clarity of detail Clear and unambiguous Care and condition Advice given Action Negative findings Frequency of the entries Spelling and grammar Missing information Patients’ details Acute admission health records How do we record? Protocols and guidelines Aggression Failure by the patient to comply Third party information Telephone advice Consent issues Language and interpreters Times and dates Authenticate Legibility Designated place for allergies Standard forms and tick boxes Fact, assumption, professional opinion Amending the records What to avoid Jargon Routine and meaningless phrases Gratuitous entries Subjective comments Abbreviations Don’t squeeze information in Don’t leave gaps Errors in the health records Common errors in the records Transmitting and receiving information Duplication of health records Sharing information Inter professional access to records Communication between health professionals Confidential information Records used for research and teaching Records used for clinical audit Access to the health records by the patient Patients’ right of access to health records Copying letters to patients Systems and retention of records Systems of record keeping Supplementary records Electronic records Further considerations Infection control and the records Mental health records Midwifery records Social care records Ownership and storage of records Who owns the health records Storage of health records Health records used to prepare witness statements and reports Health records used as evidence Will the record stand up to legal scrutiny Untrue or false records Missing records Lack of professionalism What the is court looking for Defensive records Assessment criteria for health records Glossary
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