Download Sharing and Consent

Scenario
Ethel is a 78-year-old widow with no children who lives alone in a
two bedroomed semi-detached house with three concrete steps
from the pavement to the doorstep, an internal staircase and an
upstairs loo. She has a bath but no walk-in shower.
Until now she has been fully self caring and attends the practice
once or twice a year for a medication review and for blood tests. She
suffers from high blood pressure and has been on bone protection
therapy since she broke her wrist four years ago.
At 10.15am one Thursday morning in May she stumbles on a step in
her back garden whilst hanging up the washing. She is found by a
neighbour after 15 minutes who manages to help her up and get
her into her sitting room chair. She suggests an ambulance is called
but Ethel refuses. The GP is called and a visit request is made.
The GP on call rings her back after half an hour and offers a GP visit
later.
GP access
• GP has access to complete GP record and can
assess her recent state from this.
• Implied consent for this to be seen by all in the
practice
• They can quickly scan the problem list, the
current medication, glance at the lab results for
last blood count and kidney function, why she
last attended and look at recent correspondence
• This takes about 1 minute to do
The visit
On visiting her at 12.30 the GP finds her sitting in her arm
chair, sipping a cup of tea.
She is well oriented and shows no sign of a head injury, but
has a sore back and a small cut on her shin. Her legs have
mild pitting oedema (swelling).
She’s able to get up out of the chair and walk across the
room holding on to furniture. Overall she seems stable, but
needs her leg dressing.
GP has with her a paper summary sheet with problem list,
recent consultations, medication and latest lab data
The GP decides to refer her to the community nursing team
(ICT)
How the Community Nurse finds out…
The GP returns to base and can:
• Walk into another room and ask the nurse
• Ring the nurse
• Write a message in the message book
• Send a referral fax via SPA
• Task the nurse on systmOne
• Econsult the nursing team via systmOne
DEMOGRAPHICS AND REASON FOR REFERRAL
REFERRER CHECK LIST as appropriate
New patient
Patient already on caseload
Past medical history attached
Medication list attached
Spirometry results attached
Last five consultations attached
Date of first visit/urgency of visit (as appropriate):
Patient name: Ethel Smith
…………Today………………………………..
Title:
National Health Service Number (NHS No.)
Gender:
Male/Female
Date of Birth (D.O.B.)
Current address:
Postcode:
Telephone number:
The referral-form
Does this patient live alone?
Yes/No
City Wide Alarms:
yes
Special information to access the property:
Risks:
Key Safe/Door Code:
Additional info:
Next of kin – Name:
Relationship:
Ethnicity:
Telephone Number:
Religion (if known):
General Practitioner (GP)/Consultant:
Does the next of kin wish to be
notified prior to visit:
Yes/No
First language:
Interpreter needed?:
GP Telephone Number:
GP Fax Number:
GP Practice Name/Address:
Date last seen by GP:
Consent to share information with appropriate service: Yes
Reason for referral:
Ethel has had a fall and injured her shin. Her legs are
a bit oedematous but she is mobilising.
Can you dress her legs and monitor the wounds until
you're happy.
Could you check her bloods: FBC U&E LFT TSH gluc
• Faxed to SPA, the agreed mechanism for contacting the
community nursing service /ICT ( Integrated Care Team) based
at another health centre 3 miles away.
• Apart from the demographics, the GP ignores all this and the
information completed on the form is the following:
“Ethel has had a fall and injured her shin. Her legs are a bit
oedematous but she is mobilising. Can you dress her legs and
monitor the wounds until you're happy. Could you check her
bloods please? FBC U&E LFT TSH glucose”
• The form is passed on to the local ICT who arrange to visit
later that afternoon.
• Implied consent
Referrer:
Print Full Name:
Designation:
Telephone Number:
The Community Nurse
• At 2.30 the nurse makes an assessment and
dresses the wound. Ethel’s neighbour is there
making a sandwich and tea, Ethel seems
comfortable and it seems Ethel is stable and
will get the help she needs overnight.
• The nurse asks Ethel if it is ok for her to share
her records with the GP. Ethel says yes.
• Expressed consent
The Admission
• At 10 that night Ethel falls over getting out of bed to
get to the toilet.
• Her neighbour has been kindly popping in, finds her on
the floor and phones an ambulance. A paramedic
suspects a broken hip
• She arrives at A&E unaccompanied, without any
information other than the bag of pills and the history
this tired woman can give herself
• Summary care record may be available (expressed
dissent)
• She is later found to be mildly anaemic and her
potassium is very low