Copying patients into clinical letters (Cancer Services)

Introduction

Following an NHS plan commitment, work by the Department of Health (DOH) and the publication of Good Practice Guidelines by the DOH the practice of making available to patients copies of clinician’s letters became national policy on 1st April 2004

It is now regularly mentioned in DOH publications, the Cancer Reform Strategy and National Peer Review although it has been left to individual Trusts to decide how to implement and publicize this policy.

Purpose

The Purpose of this policy is to provide a clear and safe procedure for clinical and administrative staff to follow in order to comply with National Guidelines, Peer review and adhere to the principles of best practice.

The Terms of the National Policy

The National Policy proposes that – where patients agree, letters written by one health care professional to another about a patient should be copied to the patient (or where appropriate their parent or guardian).The general principle is that it is the patients right to be copied into all letters that help to improve their understanding of the health care they are receiving.

In terms of the National Policy a ‘letter’ includes communication between different health care professionals – including GP’s, hospital doctors, nurses and therapists, and may include letters, forms of referral and discharge summaries.

Raw data such as blood results should not be copied until it can be put into an appropriate context/explanation.

Policy Details