Chapter 14

Confidentiality, consent and record keeping

Gail Vernon

Aim

The aim of this chapter is to outline the principles of patient confidentiality, consent and good practice in record keeping.

Outcome

Reading this chapter will give an understanding of the ways in which confidentiality, consent and record keeping are integral elements of professionalism.

Duty of confidentiality

Patients are entitled to expect that all the information the dental team learns and holds about them will remain confidential, even after their death. Information in respect of patients must be used only for the purposes for which it is given, and steps must be taken to prevent patient information from being accidentally revealed or accessed inappropriately. Patient information must be kept securely at all times.

The duty of confidentiality applies to all members of the dental team.

Policy statement

One of the policies that a dental team should develop and apply is a policy on confidentiality. Such a policy should emphasise the importance of absolute confidentiality, and include details of the arrangements and circumstances under which patient information may be released. The policy must apply to all members of the dental team, and other members of staff who may possibly come across any information pertaining to patients. Compliance with the policy on confidentiality on a 24/7 basis should be a condition of employment for all members of the dental team.

Safeguards

To limit the risk of any breaches of confidentiality, members of the dental team should, amongst other measures:

• avoid leaving patient’s clinical and other records lying around where they may be seen, for example by cleaners, visitors, tradesmen and other people who may have occasion to enter the dental premises

• ensure that patient record libraries are secure and, where necessary, supervised

• avoid taking patient’s clinical records out of the dental premises, thereby precluding the risk of inadvertently leaving them in a public place or having them stolen, for example, in a briefcase from the back of a car

• be in the habit of only drawing a patient’s records from the record library when they are required, and returning them to the library at the earliest possible opportunity

• keep patient’s records in use out of sight of other patients and accompanying persons

• only share patient’s record information with other members of the dental team on a ‘need to know basis’

• exercise great care when discussing a patient; conversations are easily overheard, for example in communal areas and lifts

• be careful not to breach confidentiality when talking to patients in public areas, such as the reception area

• take steps to ensure that telephone calls to patients, or about the treatment of patients with, for example, other healthcare providers, are conducted out of earshot of others, preferably in an enclosed office

• ensure that all communications in respect of patients sent by post are mailed in sealed envelopes

• take special precautions to safeguard the security of any patient information that has been computerised

• preclude the possibility of patient information being read off a computer screen

• ensure that all processing of information pertaining to patients is conducted in accordance with relevant legislation, such as the Data Protection Act in the UK.

In considering such matters, it is important to recognise the rate at which information may be disseminated. The typical individual may share an item of new information with 15 or so people within a day. If, in turn, each of these people passes on the information to a further 15 people and so on, within two to three days more than 3000 people may be party to the information. A careless release of information, let alone gossip, particularly outwith the clinical environment, may cause significant embarrassment if not difficulty for a patient. Understandably, patients affected in this way have good reason to complain and possibly take other action in respect of the breach of confidentiality.

Releasing information

If you information about a patient has to be shared with others, this must be explained to the patient, with good reasons being given, and their permission obtained and recorded in the clinical records.

If the patient agrees to certain information being shared with someone else, it is important that the patient understands what information will be shared, the likely consequences of releasing the information and that information will be disclosed in strictest confidence only. Under other circumstances, the patient may ask you to disclose information to a third party, for example for the purpose of health insurance, or for use by legal representatives who are acting on behalf of the patient or other parties. Alternatively, other people may ask you to provide patient information, possibly including images or radiographs, for example to support teaching or research. In all cases:

• obtain the patient’s consent

• make sure that the patient understands exactly what they are agreeing to and how the information will be used

• release the minimum of information necessary.

Releasing information in the public interest

From time to time it may be necessary in the public interest to share confidential information without the patient’s permission. This could be information that may prevent a patient from harming themselves or others, or to identify individuals involved in serious criminal activity. In such matters, it may, given the possible consequences, be prudent to seek advice before making the disclosure. In all such circumstances, the professional should attempt to persuade the patient to disclose the relevant information themselves, or to gi/>

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