Specific Topic(s):

Duty to ensure contemporaneous and sufficient clinical records, and to comply with requirements for information to support organisation and management of healthcare

Key references:

‘Ethical principles of health care in times of armed conflict and other emergencies’ – Ethical principles of health care do not change in times of armed conflict and other emergencies and are the same as the ethical principles of health care in times of peace.

Geneva Conventions: none are applicable

Discussion:

Review of the question: some healthcare practitioners complain about the time taken to complete medical records, especially electronic medical records. If excessive, this can detract from clinical care.

Interpretation of the principles/policy from the references:

This issue is no different in military medicine from any other type of medical practice.

Framework for answering the scenario/question:

• What ethical/professional/legal guidance already exists in regard to the duties of healthcare professionals to complete medical records? As an example, see the UK General Medical Council guidance on duties of a doctor in the further reading.

• Medical records can exist for a variety of purposes – what professional guidance exists for managing and protecting personal information, including collecting information for managing healthcare and conducting research? As an example, see the UK General Medical Council guidance on managing and protecting personal information in the further reading.

• Consider how to make a decision regarding the balance to collect as much clinical/organisational information as possible during emergency situations versus the clinical time involved?

Further issues for consideration:

• Consider whether there are different clinical information requirements for different categories of patients that might be admitted to a military medical unit.

• Consider how to separate information needed for clinical care, information needs to manage care and information needed for medical research and how the Information Governance arrangement for each of these might be similar or different.

Duties of a Doctor. Domain 1 Knowledge, Skills and Performance. UK General Medical Council. At: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/domain-1---knowledge-skills-and-performance#paragraph-19 accessed 29 May 20.

Managing and protecting personal information. UK General Medical Council. At: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/confidentiality/managing-and-protecting-personal-information accessed 29 May 20.