In this interactive exercise, David Cartwright looks at the issue of access to record cards. Work through the scenario. At the end there will be six multiple choice questions. Once you have answered these correctly (multiple attempts are allowed for interactive exercises) you will be given an interactive exercise to  complete in your workplace.

A copy of the source material may be downloaded here and further information is available on the College of Optometrists website.

An elderly patient attended for an eye examination last week and today you have received a phone call from the patient’s son.   The caller explains he is concerned about his mother and would like to know more about the examination.  He would also like to have a copy of the record card sent to him.

Are you able to comply with his request?

No

It would clearly be advisable to decline the request tactfully, in a manner that you are not seen as being awkward.  You do not know why the information is being requested and so you do not want to inflame the situation.  It may be to complain about your treatment or simply he is worried about his mother’s vision for driving.  Explain that you have to be mindful of data protection rules and you have to ensure the patient is happy for their data to be disclosed.  To be helpful advise the son what needs to be done to enable you to disclose the information.  You can comply with the request as long as you receive the permission of the patient.

You receive a call from the patient telling you that you have her permission to give her son a copy of the card.

Are you able to give the son a copy of the card?

No.

A patient or someone acting on their behalf is able to access their records, after you have received explicit consent that the patient allows you to disclose the information.

You should have written permission, signed by the patient, stating that she is happy for her son to have a copy of her record card, as it contains clinical information.  Even if you are confident that it is the patient and in this case you know the patient well you should have written consent.

What, in your view, is ‘consent’?

What is consent?

To be able to give consent this means that the patient must:

•    Be competent.  This assessment is based on the patient’s ability to understand the information relevant to the decision and can communicate the decision.

•    Have sufficient evidence to make a choice.  Without adequate information, patients are unable to make decisions and the patient should be given time to ask questions.

•    Be able to give consent freely.  If a patient is pressured into consenting this invalidates the consent.

An adult will be assumed to be capable of taking a competent decision, unless the opposite has been demonstrated. This applies just as much to older people as to any other adult.   Where any doubt does exist, this gives us a difficult scenario, especially if consent for treatment is required.    For instance the patient may be suffering from dementia which is affecting their short term memory.   In this case you will need to make a reasoned decision taking the best interest of the patient into account.  You may want to talk to another healthcare professional for their  view, for instance the patient’s GP.   Whatever you decide should be recorded on the patient’s notes.

The written consent arrives and the same day her son calls into the practice and now asks for the record card, not a copy.  

Should you give the original?

No.

The original remains the property of the practice, you should give a copy.  Of course if a practice were to close down consideration should be given to transferring the records to another practice and informing patients.  This can present a slightly difficult scenario.  Do you have to write to each patient and ask their permission to transfer their record or do you write and let them know this has happened?   The later seems to be the common senses approach, however a patient may decide that they do not want to attend the new practice and ask for their clinical information.

Do you have to give the patient a copy of the record immediately?

No.

The rules for this state that the request for records should come in writing, and the practice is allowed 21 days to provide the records where the exam took place within 40 days or 40 days for earlier records.

However, it is worth bearing in mind that there are a number of reasons why any patient may require a copy of the record.  It may be out of genuine interest to have a copy of health records, it may be because they are wanting to make a complaint about your treatment and perhaps they may want to complain about another practitioner.  Whatever is the reason it may inflame the situation if you make the patient wait for a copy of the card, when they can see it is a relatively easy task to copy it.

Are you able to charge for the copy

Yes.

However again, think of the situation.  Will this inflame a difficult situation, or is it best to make a copy free of charge?  You will be required to offer additional help if anything on the record requires clarification, such as an abbreviation.

As you are copying the record, you notice that you have not recorded advice you gave the patient with regard to dry eye.  You remember this as the patient purchased product as a result of the conversation.  You know you have done this, however for some reason you omitted to record it on the card.

Is it OK to put in the information now?

Yes, with a dated note.

Records should be made contemporaneously, i.e. they are done at the time of the examination.  In this case you could make a note, but clearly date the entry, so there is no suggestion that you have added to the card at a later date.

Points to consider:

Good record card keeping is essential in practice to protect you and the patient, and to help you provide a high standard of care.  Failure to keep good records may constitute serious professional misconduct.  The record will help you to identify issues the patient has and to follow through a course of action.  It also helps to show that you were aware of potential issues and defend actions you have taken.

In the unlikely event of a complaint about your practice, whether it goes through the General Optical Council or a civil law route, it is likely that there will be a long time between the complaint being first raised and any final conclusion.   This is inevitably a worrying time, however good records will enable you to defend yourself and be confident of a positive outcome.