This medico-legal series covers key topics of interest to early career doctors, such as consent. capacity and other professionalism issues.
Consent is an essential requirement for any medical procedure, intervention or prescription, except in emergencies. It can be verbal or written. In some facilities or for larger interventions, such as surgery, there may be policies about the type of documentation and the required experience level of the doctor undertaking the consent process.
Capacity is defined as a patient’s ability to make decisions. This varies depending on the complexity of the decision needing to be made.
Detailed patient records are essential for the efficient and safe ongoing care of patients. There are also ethical and legal factors to consider when you are creating, maintaining, storing and using medical records.
Open disclosure refers to the discussion between healthcare professionals and patients, or those close to them, after a patient experiences harm during their care.
Privacy and confidentiality are important considerations when dealing with patient information. These terms are often used interchangeably and can be misunderstood. In practice, it can be confusing to work out what you can and cannot say to a patient’s family or how and when it’s acceptable to share their information.
Professionalism refers to the professional values such as compassion, self-awareness, honesty and integrity that form the basis of medical practice. In Australia the expectations are outlined by the Medical Board of Australia: Good medical practice: a code of conduct for doctors in Australia.