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I once wrote a short book containing health advice aimed at the public. My wife acted as proof reader and each chapter was returned with red lines, well, everywhere. The problem was that I had tried to give a clinical explanation that was unintelligible to a layperson – as evidenced by my wife. In other words I had used too much `health-speak`.
It`s even worse when it comes to writing our clinical notes. We are rushed and take shortcuts. So, in addition to using clinical terms we add in shortened words, initials, acronyms and our own codes. That`s OK because only we are going to read them, right? I`m sorry but no!
Now, the Information Commissioners Office (ICO) has announced that the health care sector was responsible for around 600 of the 6,000 complaints over Subject Access Requests (SAR) in 2012/13. These requests are one route used by patients to obtain copies of information that an organisation, such as a GP practice, holds about them, including where their information is being held, whether it is being processed, and if so why. Following this large number of complaints, the ICO advised GPs to explain complex words used in health records and provide definitions of terms that a lay person might find difficult to understand. It also said acronyms and test results should also be made intelligible. The ICO `requires that the information you supply to the individual
is in intelligible form. At its most basic, this means the information
should be understandable by the average person.` The ICO’s guidance also says: ‘If the information includes complex terms or codes, then make sure you explain them.’
The practical consequences of this guidance are that either all original notes need to be written in a form readable by a patient or that any request for copies needs to be accompanied by an explanation of all terms used, conditions, tests, and treatments. Handwritten notes need to be accompanied by a transcript enabling patients to read them easily.
Remember that anyone using this avenue to access notes and personal information is probably already anxious and has a concern about the nature of information. At one end of the spectrum, it would be politic to help with transparency and to help with expanding an understanding of the content. At the opposite end, to be complicit in making it difficult to understand the content would be to make the situation worse.
Dr. John Shapter – QCS GP Expert Contributor