11.9, 11.10 Legal Documentation & Legal Aspects Death/dying Em

Front 1

Regarding documentation/medical records in the ED, Cam p. 773, Dunn 171 - true or false
1. secure disposal e.g. shredding of patient documents is a part of the national privacy principles
2. computerised data should be accessible only by password protected access
3. patients requesting access to their medical record must provide a reason
4. primary purpose is to facilitate provision of continuous patient care
5. 5% of claims of defence of a medical practitioner are compromised by poor records
6. should include nature and duration of any medical certificates
7. unrestricted medical record access is enshrined in national privacy principles
8. 3rd party access may occur with the approval of an institutional ethics committee
9. 3rd party access may occur as part of a formal quality improvement activity
10. new medical record forms must meet Australian standard AS2828

Back 1

1. t
2. t
3. f - no reason required
4. t
5. f - 40%**
6. t
7. f - must make application under freedom of information; unrestricted access provides potential fro misinterpretation, and may be distressing to patient
8, 9 - t, also to other parties e.g. legal with the written consent of the patient
10. t - governs size of paper, pt ID location, hospital name/logo, two holes...etc. etc - everything on the sheet is regulated

Front 2

Elements of a medical record include...

Back 2

Date/time consultation, also date/time of record entry (if significantly different)
Clinical assessment
Data synthesis - dx, ddx
Management
Communication e.g. advice to patient, information from other specialities, patient, family concerns
Disposition
Identification

Front 3

Pros and cons of electronic records

Back 3

Pros - accessible, shorter searching time, multiple simultaneous users, decreased likelihood record mixing

Cons - easier UNAUTHORISED access, $$$, requires complex and reliable network systems, may not be accessible at bedside, require good data entry skills by staff, pictures/diagrams more difficult to enter

Front 4

Legal aspects death and dying Cam 761, Dunn 222+ T/F
1. all property in the patient's possession is considered part of the patient's estate and may not be given to relatives once the patient has died
2. if unable to complete a death certificate due to uncertainty about cause of death, it may be appropriate to ask the patient's regular doctor

Back 4

1. t - however as per Dunn common sense applies, items of significant emotional and monetary value are a difficult area. Weigh circumstances and given to relatives if appropriate but ensure DOCUMENTATION
2. t

Front 5

Regarding end of life decisions and advanced care directives which is incorrect
1. A medical enduring power of attorney is a legal document appointing another person (the agent) to make medical treatment decisions on a patient's behalf, but only if they cannot make or communicate decisions themselves
2. A general power of attorney may make medical decisions
3. A refusal of treatment certificate (RTC) is a legally binding document about medical treatment that is not wanted for future medical conditions
4. Palliative care cannot be refused by an RTC
5. A Medical Power of attorney can complete an RTC on a patient's behalf if they become unable to make decisions
6. A Statement of Choices is a document of a patient's medical treatment wishes to assist those making decisions for them when they can no longer do so for themselves.
7. statement of choices and RTC's are both forms of advanced care directives (a formal written document, which is part of an ADVANCED CARE PLAN)

Back 5

1 t
2 f - only medical
3 f - only for CURRENT medical conditions
4 t
5 t
6 t
7 t

Front 6

Regarding the Victorian Coroners Act 1985 which is incorrect
1. normal constraints of obtaining consent for the provision of clinical information to a third party do not apply in regards to information provided to Coroner
2. to issue a death certificate, a doctor's knowledge of patient may be limited to having examined the body after death
3. to issue a death certificate, a doctor's knowledge of the patient may be limited to caring for the patient immediately before their death
4. the Act enables police to have control of a body whose death has been reported, and they may then allow the Coroner or his agent access
5. prior to or during Coronial investigation, mistakes or omissions in care should still be discussed with family and steps to prevent recurrence made by the hospital

Back 6

4. the Coroner has control of the body, and the police may act as the Coroner's agents