When patient information can’t be unknown but can’t go in the notes

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When patient information can’t be unknown but can’t go in the notes

Emma Dunning

Emma Dunning

Dr Emma
Emma Dunning is a Wellington GP

DR EMMA

Emma Dunning has been pondering the role of information about the patient but not from the patient

Ought I to write information from collateral sources into the notes? I think not. There shouldn’t be anything in there the patient doesn’t know about , Emma 14 march

Comments

You are the  big brother in  health. WINZ   for  care givers certs, fostering   certs,  Disability  allowances , Jobseeker  medicals for  work,  Insurance  companies. If no  one  recorded  marijuana  use ,  A&D  attendances , STD  attendance  , counselling  consults  alcohol  convictions , but you  know of them  do  you  report on  the  information in your head ? If an insurance  company   turns a  client  down  and you  ticked the  box about sharing  with  the  patient   they  will  ofter send the  patient  back  to  the  doctor   to  explain  why  they  were declined ?

At what stage are  you   going  to invoke  the   enduring  power of  attorney  for  property  and personal  welfare .? Does  she have one?  Do  you  know  who  it is  and  have  you  got copies of the  EPOA   scanned into  her  notes  (  In a  readable  and  printable   quality ?) What if she   wants to  change  the  EPOA  and  not  make  the  son   the   property   manager  or  welfare guardian.  Not  infrequently  the   lawyers   will  want a letter  from  the   GP   to  say  she  is  competent  or  not  competent   , but does not  specifically   state  with regards to  what   decision . What  if 5 years  earlier  Mum  had said   the  son  had  spent  time  in jail  for    defrauding  an elderly  person  for  whom he was a  caregiver ? Where did  you  put that  information . Recently   the  local  paper  was  having  a  poor  news  day and a reporter wrote an article  about an ACC  court case   that  happened   over three years  ago. If you  were the    claimant's  GP    would  you  add that   to  the  patient notes  if you hadn't  known that ?  There are now 53  Urgent Care Clinics   in  the  country  doing  2.5 million   consults  annually. Do  you  update  the errors  and  data  from  their  reports  about    never been  a smoker ,safe  alcohol intake  (  Not what the    judge said in the newspaper  drink  drive convictions reports ), patient reports  was unsafe in   the  home  but  not   now,  cell  phone  numbers ,  next of kin , terminations, marijuana  use ,  ACC claims even if  spurious ? All  of this  stuff is  hearsay   and may actually  be  heresy . 

Do  you  look  up  the  lab results to  see what  medications  were dispensed in  the  community  and when, STD  results? Do  you  have ALL  the  old ACC claims  and numbers   and diagnoses recorded ? One patient  reported  they  had  been  in hospital   for  months  following a  severe accident . None of the  last  5 practices  had recorded  any  ACC numbers,  dates  or  list of injuries missing out on  thousands of  dollars of   potential  claims . The  Exported  data  from  GP2GP   lists  the    initials of the  service  provider  from  Medtech  but  the   data  showing up in  the   MT32  import  just lumps all  providers  Dr,nurse,  counselor  , PA, PN , NP, ancillary staff  data as provided by EXT .