Criterion 1.7.3 Consultation notes
Each of our patient health records contains sufficient information about each consultation to allow another health professional to carry on the management of the patient.
► A. Members of our clinical team document consultations including consultations outside normal opening hours and visits to living quarters in patient health records as follows (health records review):
- date of consultation
- patient reason for consultation
- relevant clinical findings
- recommended management plan and where appropriate expected process of review
- any prescribed medicine (including medicine name, strength, directions for use/dose frequency, number of repeats and date medicine started/ceased/changed)
- any relevant preventive care undertaken
- any referral to other healthcare providers or health services
- any special advice or other instructions
- identification of who conducted the consultation, eg. by initial in the notes, or audit trail in electronic record.
► B. Our patient health records show evidence that problems raised in previous consultations are followed up (health records review).
A consultation is an interaction related to the patient’s health issues that takes place between a health professional in the health service and a patient. A consultation may be with a doctor (GP or other specialist medical practitioner) or with another member of the clinical team who provides clinical care within the health service (eg. nurse or psychologist).
The quality of patient health information needs to be such that another health professional could read and understand the terminology and abbreviations used, and from the information provided be equipped to manage the care of the patient. Documentation of all the items in Indicator A will not be required for every individual consultation, such as consultations for repeat prescriptions.
Ideally, information about the consultation needs to be entered into the patient’s health record as soon as is practicable (eg. during or immediately after the consultation or as soon as information such as test results becomes available).
As part of the continuing care that health services in prisons provide, information concerning patients is gathered over more than one consultation. It is important there is a connecting process so that information about clinically significant, separate events in a patient’s life and in the care provided are not overlooked but are recorded and managed in a way that makes this information readily accessible. Regularly updated health summaries are one method of managing patient health information. Clinically significant information may include the patient’s health needs and goals, medical conditions, preferences and values. All this contributes to care that is responsive to a patient’s individual needs.
Medical defence organisations have identified lapses in following up on problems and issues raised previously by patients, as a considerable risk. This scenario can occur when earlier consultation notes are inadequate, or when patients are not seen by the usual member of the clinical team, although it can also occur when a staff member is busy or distracted. Therefore, to sustain safe and high quality patient care it is useful for health services to have systems, including systems for consultation notes, that reduce the risk of such lapses.
It is also important for health services in prisons to document in a patient’s health record if there is a delay (for whatever reason) between the patient requesting healthcare and the provision of that healthcare. It may be useful for medicolegal purposes to document the reason for the delay and the follow up that occurred as a result.