Patient's Files

bobbyss

A friend of mine is in hospital with all sorts of problems. Very complicated issues. She doesn't know who her consultant is or who exactly is treating her. How can she get a handle on all of this? Therexserms to be a total lack of communication.

What information is on those files on clipboards at end of beds in wards? Are they private? Should they be secured?

Victor

bobbyss wrote: »

A friend of mine is in hospital with all sorts of problems. Very complicated issues. She doesn't know who her consultant is or who exactly is treating her. How can she get a handle on all of this?

Just have your friend ask the nurse. Any questions they can't answer, ask the doctor when they come around. Keep notes.

Therexserms to be a total lack of communication.

This might have been communicated, but absorbing lots of information can be difficult.

What information is on those files on clipboards at end of beds in wards?

I imagine patient name, patient number, illness, then it's stuff like temperature, heart rate, blood pressure, medications, special instructions (no food before surgery, etc.), etc. There may be other information

Are they private?

Medical staff and the patient are allowed read them

Should they be secured?

Good question. There may be a matter of balancing privacy against medical necessity (making sure the right details are marked against the right person, especially in an emergency).

GM228

Victor wrote: »

Good question. There may be a matter of balancing privacy against medical necessity (making sure the right details are marked against the right person, especially in an emergency).

I remember reading something about this somewhere a long time ago (not sure where but the EU29 WP rings a bell) where it was deemed unacceptable, and the DPC has recently released a report into this recommending they should be secured in a protected environment as it is a legacy practice which pre dates DP law.

Data Protection Investigation in the Hospitals Sector

Observation charts are widely used in hospitals throughout the world. These are essential documents that allow for the recording of patient physiological observations during their hospital stay.

Varying levels of physiological details may be recorded on observation charts depending on the type of chart used. Most observation charts are used to monitor, at a minimum, the patient’s vital signs such as body temperature, heart rate or pulse, respiratory rate and blood pressure. Usually the patient’s full name and date of birth are recorded on the observation chart.

The physiological details recorded on an observation chart in respect of an identifiable patient renders the content of the chart to fall into the category of ‘sensitive personal data’ within the meaning of the Acts. For the purposes of the GDPR, such physiological details fall into the definition of ‘data concerning health.’

In some of the hospital facilities inspected, as standard practice, patient observation charts in respect of admitted patients are clipped to the end of each patient’s bed. Where the patient is admitted to an isolation ward, it is standard practice in some hospital facilities to hang the patient’s observation chart on a wall rail immediately outside of the patient’s isolation ward, usually in a corridor area. In both of these situations, as the observation charts are unprotected and unsecured there is a high risk that the observation charts of patients could be viewed or accessed inappropriately by third parties such as other patients, visitors or other members of the public.

As data controllers, hospitals are obliged to take appropriate security measures against unauthorised access to or disclosure of personal data.

The practices outlined above are inherited ones that pre-date data protection law. Unfortunately, these practices lend themselves to situations whereby the personal data of patients is exposed to snooping third parties, such as visitors in particular. Patients have a right to have their personal data that is recorded on observation charts fully protected and the responsibility for protecting that personal data rests with the hospital concerned.

Recommendations

Where patient observation charts are currently clipped to or left hanging on the ends of patient beds, they should in future be stored securely in a protected environment, in the immediate vicinity of the patient’s bed if necessary, where they are accessible only to hospital staff who have a professional need to access them