First and foremost, patient confidentiality should not be confused with our right to privacy. Patient confidentiality is, nevertheless, protected by law. This is why medical physicians take an oath that they will protect their patients’confidentiality. This opens the lines of communication, without the worry that the physician will expose any of the patients medical information to others. This takes away the fear out of seeking professional help. The ideal is enforced by the Data Protection and Patient Confidentiality Act of 1998. It was brought in to help make us feel at ease when speaking to our physicians. After all, when a patient is willing to be open and forthcoming with information, the physician can accurately diagnose their condition(s). In return, the patient will get effective medical care.
What Is Included In Physician-Patient Confidentiality?
Confidentiality includes information that a patient shares with their doctor, as well as the results of medical opinions or findings during an exam. All medical records are included in confidentiality, such as medical history, x-rays and labs. Any communication between the patient and doctor is also covered by confidentiality.
It is important that confidentality remains after someone passes away or when they stop seeing a named physician. If information is presented with the correct authorisation and this act, alone, causes a patient to harm themselves, then they have a right to file a lawsuit against the medical representative.
When Do You Break A Patient’s Confidentiality?
Unfortunately, this inherent confidentiality needs to be broken when a patient is seen as a danger to themselves and/or others. In this case, their immediate physician needs to collobarte with other medical professionals in order to determine the right course of action as quickly as possible. Their expertise may also be called upon for occupational health services to help identify the culprit(s) and intent behind a criminal offence. Equally, there are instances when these medical professionals are called in for disrepute. In all of these instances, disclosing patient information is a vital component of the British jucicial system. In these scenarios, the court relies upon a consultant psychiatrist to produce a medico-legal report.
What Is A Medico-Legal Report?
A medico-legal case can, therefore, be defined as a legal case in which investigations are needed to conclude the causation of a given injury or event. To come to a factual conclusion the consultant psychiatrist must understand a defendants medical history along with an in-depth examination of their current mental state.
The report has a specific format, and will need to be carefully prepared. All information within the document must be factual, and pertain to the reason for the preparation of the report. Those who may request a medico-legal report includes police, lawyers, court proceedings, insurance companies and the patient themselves.
The report can be used in criminal and civil proceedings. The outcome may include consequences for the patient, physician or another party. That is why it is vital that the medico-legal report be prepared with accuracy, thoroughness and with the extreme understanding of the law.
A court room often requires an in-depth psychiatric capacity assessment. This could range from evaluating the state of an individual’s mental condition; understaning the cause for abnormal or irratic behavior; the severity of any cognitive impairment and traumatic psychosis.
However, a major issue to consider is the fact that a court case is a very emotional experience, and the patient is more likely to have intensified emotions or, at least, experience emotions that they would not normally feel.
Things To Keep In Mind When Writnng a Medico-Legal Report
Medical consultants need to make the upmost care when preparing a medico-legal report. As Patient confidentiality remains at the heart of this matter it is imperative that they obtain written, verbal or implied consent from the person requesting the report.
Medico-legal reports must contain facts that surround the situation, which triggered the report to be prepared. It must be based on medical records and the physician’s knowledge of the patient. Before writing the report, The patient’s medical records should be thoroughly examined.
The reports should be simplistic in nature, and information should be provided in a straightforward manner. Events will need to be listed out in chronological order. All information will need to be supported by physician notes, that were made after each visit with the patient. That is why it is so important for physicians to be thorough when writing examination notes.
The language used in the report should cater to the audience that it is being prepared for. Physicians will want to exclude any medical terminology that is not common. If uncommon terms are used, then they need to have a good explanation to give the audience a better understanding of the term.
Medico-Legal Report Format
The format will highly depend on the person who is preparing the report, as well as the person requesting it. However, there are some common elements that will always be included.
The basic format will include:
- Date of preparation.
- The person preparing the report.
- The patient’s full name, date of birth and hospital medical record number.
- Physicians full name, address to practice, current employer and qualifications.
The format will also vary according to jurisdiction. The report is a legal document and will need to be sworn in by a legal official.
Medico-Legal Report Structure
The focus of a report needs to be placed on the facts that surround the nature, which promted the report. Detail and accuracy are a must. The report should have the correct structure, so the individuals requesting the report can easily find the information that they need.
The structure of the medico-legal report should include:
- Background – This section will need to include time, date, place and reason for the examination. Details will need to be included about why the patient was there, and what was discussed. Any accounts that include details of the offence need to be added to this section. Many times, physicians will provide quotes that include evidence to the case. There will need to be a mention of consent in this section as well.
- Medical History – Summarize medical history that is relevant.
- Examination – A short description of the patient’s presentation, such as emotional, psychiatric and intellectual state need to be included. If the patient was under the influence of drugs or alcohol, those need to be mentioned. Include any information found on the exam that is relevant. Plus, any issues that are encountered during the visit.
- Specimens – Any type of specimens that were obtained need to be mentioned. This should include the site that the specimen was taken from, how it was labelled, the reason for obtaining the specimen and how it was handled. The date, time and whom the specimen was transferred to, need to be included as well.
- Management – In some instances, the physician may need to mention investigations, procedures and management of the patient.
- Opinion – It is always important to point out what information is fact, and which is opinion based. Facts will include all things that were visually seen or done, where an opinion will be an assumption. This is hard, because physicians are often brought into cases to state their professional opinions. They have the skills to look at the documentation and come to a conclusion. The court will make a decision on rather the physician has the right expertise to provide an opinion.
Here are a few examples to help you on your way.
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