1. A 44 year old woman presents with a suspected breast lump. She accepts the offer of a chaperone during the examination, and a healthcare assistant is present throughout the examination. With regards to the medical record, which ONE of the following is correct?
A. The fact that a chaperone was present does not need to be noted.
B. The fact that a chaperone was present should be noted, along with their identity (including name and job role).
C. The fact that a chaperone was present should be noted, but no further details are necessary.
D. The fact that a chaperone was present should be noted, along with their job title only.
E. Details of the chaperone should be noted only with the chaperone’s permission.
The correct answer is B: The fact that a chaperone was present should be noted, along with their identity (including name and job role).
GMC guidance recommends that where a chaperone is present during an examination, this should be recorded, along with the identity of the chaperone. The job title alone is not enough as it may be difficult to identify exactly WHO chaperoned (e.g. there may be many receptionists).
2. One of your patients asks if her daughter has been prescribed the oral contraceptive pill. Her daughter is 14, and was seen on her own a week earlier, and prescribed the combined oral contraceptive pill by one of the other doctors in the practice. Which of the following is the most suitable action?
A. Provide information if the mother has parental responsibility.
B. Explain that you are unable to disclose information without the daughter’s permission.
C. Explain that her daughter is taking contraception but that you cannot divulge details of the exact prescription.
D. Advise the mother to put in a request to access the notes in writing.
E. Provide full details as the mother has a right to know.
The correct answer is B: Explain that you are unable to disclose information without the daughter’s permission. A mature child who is competent to make a decision about their own care has the same rights to confidentiality as an adult. In this case, if the girl was mature enough to be treated without parental involvement (she was seen on her own), then you should not disclose details of her care without permission, unless failing to do so might put the patient or a third party at risk of serious harm or death, or it is in the public interest, or you are required to do so by law.
3. Regarding sharing confidential information relating to knife wounds, which of the following statements is incorrect?
A. In some cases, the name and address of the patient need not be disclosed to the police when initially contacting them.
B. You should usually let the patient know if you are contacting the police.
C. Details of all patients that present with a knife wound should be reported to the police.
D. Where there is a risk of serious harm to others, you can disclose details to the police even if the patient refuses consent.
E. In some cases it is acceptable to disclose confidential details without first seeking the patient’s consent or letting them know you are contacting the police.
The correct answer is C: Details of all patients that present with a knife wound should be reported to the police. This is a tricky question as it is negatively framed – the question asked which option is INCORRECT! This statement is incorrect as you do not need to report knife wounds if they are accidental or a result of self harm. Further details are available at http://www.gmc-uk.org/Confidentiality_reporting_gunshot_wounds_2009.pdf_27493825.pdf
4. You receive a request for a medical report based on a patient’s notes from an insurance company. The request includes signed consent from the patient to allow you to provide this information. The patient contacts you asking to see a copy of the report before it is sent to the insurance company. The patient does not have any significant medical problems. What is the most appropriate way to deal with this request?
A. Contact the insurance company and request their permission to give the patient a copy of the report.
B. Tell the patient that he should request a copy from the insurance company.
C. Tell the patient that it is not possible for him to see the report, but that he can request access to his own records.
D. Provide a copy of the report to the patient before sending the original to the insurance company.
E. Provide a copy of the report to the patient after sending the original to the insurance company.
The correct answer is D: Provide a copy of the report to the patient before sending the original to the insurance company. The GMC guidance on confidentiality recommends that you offer to show your patient, or provide a copy of any report about them for insurance or employment purposes before the report is sent. There is no need to contact the insurance company to request their permission for this.
5. How long must a practice retain confidential electronic medical records after a patient registered at the practice dies?
A. 5 years
B. 10 years
C. 20 years
D. 25 years
The correct answer is E: Indefinitely. Department of Health guidance recommends that electronic patient records should not be deleted or destroyed after a patient’s death – they should be stored indefinitely. Where the patient had paper records only, these need only be retained for 10 years after the patient’s death. Further details from the guidance is available at http://www.nhs.uk/chq/Pages/1889.aspx?CategoryID=68&SubCategoryID=160
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