A great deal of inter- and intra-professional medical communication takes place by telephone. As with electronic communication, the lack of visual cues may make this form of information exchange more difficult. In this telephone conversation we can review the difference in worldview between two health professionals. What is the source of tension in this conversation? Think about how different cultures view time. In this case, Dr. Burnside thinks two months is a long time, the nurse thinks differently. Do they understand each other’s concerns? Do they find common ground?
Communicating with adolescents
Part 4, continued
Reflective exercise 5
Inter/Intra-professional telephone communication
Legal and management issues related to medical records and other clinical information
Policies concerning medical records vary from province/territory to province/territory. This quiz is based on Ontario policies and regulations. While it brings up issues that are common to practice anywhere, the answers provided here may not be applicable in other provinces or territories.
Check only one answer unless instructed otherwise.
Most of the information needed to answer these questions for the province of Ontario is found in the College of Physician and Surgeons of Ontario Policy # 5-05. (If you are not in Ontario, there is a similar policy in effect that would be available through the medical regulatory authority in your province or territory.) Read these policies and the additional literature suggested to thoroughly understand issues related to written medical communication and patient confidentiality (e.g., the Personal Information Protection and Electronic Documents Act).
The answer to Question 1 is 10 years, by regulation. However, the College recommends retaining records for 15 years because, in some instances, physicians may be legally liable for that period of time.
Question 3 is addressed in the College Policy on Confidentiality. Voice messaging and email are frequent methods of communicating with patients. However, the possibility of breaching confidentiality is a major concern. One should not leave a voice message without asking the patient first if that is acceptable, since you do not know who else may hear it. The same is true of email communication with patients, which will also become more frequent, especially for routine work such as appointment reminders.
For Question 4, either fax or emailing a form may be acceptable, so long as you know that the process is secure. If you have concerns then give the information to Kelsey who can share it with her mother if she wishes. In Ontario, if a child’s or adolescent’s chart is released to any third party, all reference to family members is to be excluded. (See CPSO Policy on Confidentiality.) Similar policies are in place in the guidelines of the medical regulatory authorities in each province and territory. Also, in giving any office chart to any patient, whether sealed or not, make sure there is nothing written in the chart (e.g., derogatory remarks) that you do not want the patient to read.
Questions 5 and 6 are discussed in individual provincial and territorial medical regulatory authority policies on medical records and Question 7 is discussed in Dodek and Dodek. With regard to Question 8, it is also discussed in medical records policies, but the answer is of course, maybe — it depends upon Dr. Burnside’s assessment of his daughter’s maturity and understanding of confidentiality. In a small town, physicians and office staff can often know some patients personally as well as professionally. The distinction must be carefully maintained in terms of both confidentiality and boundaries.
The case continues
For the next six weeks, Dr. Burnside does not see Kelsey or her mother. Then one day …
Dr. Burnside sees Mrs. Cournoyer again. She is calmer and has arranged for her mother to help out while she takes Kelsey to her appointment. Dr. Burnside gives her a sealed envelope that contains a copy of Kelsey’s chart. On the train trip to the Medical Centre, Mrs. Cournoyer opens the envelope and reads the chart.