Legal Aspects of Documenting Patient Care

Scott, Ronald W.

doi:10.1097/01445442-199507000-00014

Cited by 1 publication

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“…Buchanan 2004 considers that case notes are not just aides‐memoirs for doctors but are complex documents that can be used for teaching, research and clinical audit, as well as evidence in the event of litigation. Scott 2000 has shown that clinicians make significant decisions, but still involve patient and family views in only a minority of cases, and that an assessment of capacity and best interests if they lack capacity is rarely explicitly documented. The code of practice (Mental Capacity Act 2005.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of a structured assessment framework to enable adherence to the requirements of Mental Capacity Act 2005

Ramasubramanian¹,

Ranasinghe²,

Ellison

2011

Brit J Learn Disabil

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Accessible summary The Mental Capacity Act is a new law that started in 2007. It says that everyone must be helped as much as possible to make his or her own decisions. But people with learning disabilities may find it difficult to make a particular decision and another person may have to make it for them. The new law provides important safeguards to the rights of people who cannot make decisions for themselves and also provides guidance for people working with them to deal with such situations. It is very important to follow the requirements of the Mental Capacity Act, and it is a legal requirement. We looked at how we dealt with situations when our patients could not make decisions for themselves and also looked at whether a checklist we made helped us to make decisions according to the new law. The results showed that people were not always following the new rules of the Mental Capacity Act before we gave them our new checklist. Using our checklist helped people making decisions for people with learning disabilities in a way which fitted in better with the new Mental Capacity Act. Summary The Mental Capacity Act 2005 for England and Wales received Royal assent in April 2005 and came into force in 2007 (Department of Constitutional Affairs, 2007). The Mental Capacity Act 2005 provides a statutory framework to empower and protect vulnerable people who are not able to make their own decisions. The adherence to it is a statutory requirement, not just guidance. An audit looked at the quality, thoroughness and completeness of making decisions for people with learning disabilities who lacked capacity in making specific decisions for themselves. We re‐audited the same using a checklist made with the requirements of the Mental Capacity Act in mind. The audit showed that the use of the checklist enabled a structured discussion to take place regarding the decision‐making process and ensured complete documentation. It facilitated full adherence to the Mental Capacity Act and established better standards of clinical practice.

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Section: Discussionmentioning

confidence: 99%