Emis Web - Recording of Domestic Abuse and MARAC information on Electronic Medical Records (EMR)
All recording of domestic abuse information
- ALL information in the EMR (Electronic Medical Record) about domestic abuse MUST be hidden from Patient Online Access.
- Family records should be linked in practices where possible.
- The name of anyone accompanying a patient in a consultation should be documented.
- The name of any alleged perpetrator/s should be included when documenting disclosure of DA.
- Ensure that any reference to DA on a victim’s records is not accidently visible to the perpetrator during appointments. The computer screen showing the medical record should never be seen by third parties (i.e. family or friends accompanying a patient). When providing a summary printout for a hospital admission for example, care should be taken that information about DA is not inappropriately included when printing out these summaries to give to patients as the perpetrator may see this. Please remember that when a Full/Brief Summary is printed off from a patient record everything will be included and any padlocks will be ignored. Therefore Summaries will need checking and any information about domestic abuse must be redacted.
- Never disclose any allegation to the perpetrator or other family members.
- Ensure that any decision to record the information in the perpetrator’s EMR is made with due regard to the associated risks.
- Ensure that any reference to DA in a perpetrator’s record is redacted if provided to the perpetrator unless you are certain it is information that the perpetrator already knows. For example, the perpetrator has disclosed this information themselves to you, or there is a relevant conviction which the perpetrator has disclosed or is aware has been disclosed to you such as in Child Protection Conference minutes when the perpetrator has been present at the conference and is aware this information is being shared.
- Be aware of the potential danger of the perpetrator having access to information about their abuse and to information in children’s EMRs; this includes via online access to their own information and their children’s information, as well as coercive access to the victim’s EMR.
- If you are not sure whether someone is a victim or perpetrator of abuse, or there is suggestion or evidence that someone is both, we recommend following the guidance on documenting victimisation.
Information about third parties and information that may cause serious harm to either the patient or others should be redacted. For example, ensure that any reference to DA/MARAC is redacted from children’s records if provided to the perpetrator.
1.0 Victim Record
1.1 If a patient discloses domestic abuse, record this information within the Patient Warnings section of the patient record in free text.
1.2 With the patient active, double-click on the Precis bar to open it. Select Manage (right-hand-side) and from the Manage Patient Warning screen click Add. Enter the text as example shows above, selecting (ticking) all the relevant Trigger Points. Select Allow this warning to be viewed by other organisations and click OK. This warning will appear every time a consultation is added for the patient. The clinician will view the warning and select Close.
1.3 Record the disclosure in the main body of the patient care record (in Problems section of a Consultation)
1.4 With a new consultation open, click once on the Problem heading, with the cursor flashing start typing the relevant clinical term: History of domestic abuse or Victim of domestic abuse etc. As you enter the relevant terms/codes will appear within the list. Double-click the relevant term from the available list. This example shows the selection of 'History of domestic abuse'. On selection the Problem has now defaulted as Significant and will remain an active problem for 84 days.
1.5 The length of time to be stored on the list of active problems should be requested by the clinician when inputting this information. The clinician can change the default setting for the practice from 84 days to a more suitable timeframe of 365 days, for this and any future recordings of History of Domestic Abuse.
1.6 Click into the Day(s) active field and enter 365 and place a tick in the Set as default duration for organisation. After the set time the problem moves to Significant Past history of Problems section of the care record.
1.7 Click once on the Comment Heading and with the cursor flashing enter free text to include what the patient has said in their own words and any relevant information.
1.8 Click Save on the ribbon to save the consultation. This Problem will automatically be added to the active Problems of the patient's care record for the required duration.
1.9 The clinician can request that this consultation and problem is stored as Do not display on the patient’s online care record, so that it will not be visible if a patient requests to see their records online.
1.10 This option is available whilst a clinician is adding a consultation by selecting Online Visibility option on the ribbon and then selecting Do not display on the patient's online care record.
1.11 This option can also be added in retrospect, i.e. hidden from online access after a consultation has been made. Right click on the required consultation entry (blue header) as shown above and select Online visibility from the available options, then select Do not display on the patient's online care record. Any information that has been hidden from online visibility will be represented by a computer icon with a red cross.
1.12 A confidentiality policy can also be applied to a consultation so that only certain staff groups within the practice will be able to see the consultation information i.e. a Doctor. To Apply a policy during a consultation, the clinician must select Confidentiality on the ribbon and then select an appropriate policy from the options available, then click OK.
1.13 A Confidentiality Policy can also be applied to a consultation in retrospect by right clicking on the consultation and selecting Confidentiality and then selecting Change/Apply Policy.
1.14 When a Confidentiality Policy has been applied to a consultation it is represented by a padlocked icon. The screen shot below shows how the consultation has been hidden from online visibility and applied with a confidentiality policy.
1.15 Please note: If the patient moves to another surgery, out of area, the information will be visible in the list of Problems and Consultations but Patient Warnings information will not be transferred.
(within the household record)
1.16 Add to the record following the same procedure as above, including online visibility protection.
1.17 If an adult victim/child discloses domestic abuse, ensure perpetrator’s record is linked to the record of the victim, any children or any vulnerable adults within the household. Do not record the disclosure in the alleged perpetrator record unless your professional judgement deems it necessary. Apply online visibility protection if any information is recorded.
2.0 If a child discloses domestic abuse follow the same procedure as for when a victim discloses domestic abuse in Section 1.0 Add to the non abusing parent record and to any sibling/vulnerable adult within the household records. Ensure the perpetrator’s record is linked to the record of the victim, any children or any vulnerable adults within the household.
2.1 Double-click the Precis bar and check the Household button for other household members:
2.2 Do not record in the perpetrator record unless your professional judgement deems it necessary. Ensure online visibility protection is applied.
2.3 If a patient discloses that they are a perpetrator of domestic abuse add these details in free text to the Patient Warnings. Record the disclosure in the main body of the record (within the Problems section of Consultation) – include what the patient has said in their own words and any relevant information. Add the relevant code – ‘Alleged Perpetrator of Domestic Violence’ this will automatically be added to the active Problems.
2.4 Use the online visibility protection to hide this consultation from online access.
Adult Victim, Children or Vulnerable Adult Record
2.5 If a patient has disclosed that they are a perpetrator of domestic abuse add the disclosure to the consultation page as stated in Section 1.0 above ensuring online visibility protection applied.
Victim or children subject of MARAC
2.6 Information sent to LSCFT pre MARAC should be stored by the clinician as a scanned in document in the victim and child records. Apply online visibility protection and padlock the document. Add a Patient Warning stating that the victim is subject of MARAC as a victim/child and add any significant risk factors.
2.7 At the point of scanning, from the browse (looking glass) icon select a document Type of 'Subject of multi-agency risk assessment conference' as above and browse to select the appropriate Source. The Document Title field will become pre-populated with both the Type and Source fields combined. The Document Title accompanies the attachment (paperclip) that is recorded within the Consultation/Documents/Care History tab of the patient's care record.
2.8 Record in consultation that information has been shared with LSCFT regarding MARAC and that the patient is named as a victim/child subject to MARAC. Add the above code as a Problem, this will automatically be added to the list of active problems you can then apply the online visibility option and ‘padlock’ with the application of the confidentiality policy. Any feedback received from MARAC should be scanned into the patient record padlocked and redacted if patient requests to see the records.
2.9 GP Practices must never share information related to MARAC with an alleged perpetrator, doing so would be dangerous to the victim and likely to increase victim risk. Any information sent by the GP Practice to MARAC via LSCFT should be scanned into the record and marked as confidential/padlocked and protected from online visibility. Codes should not be applied. The Royal College of General Practitioner updated guidance advises not to record any information received from MARAC. LSCFT will only feedback MARAC information related to perpetrators if they feel that the information is necessary for the GP to be aware of. If the GP feels in their professional judgement that it is necessary to store the information received then any information that is stored should be protected from online visibility and redacted from any subject access requests.
2.10 Add “Named/alleged perpetrator” to the Patient Warnings. Add to consultation page and apply codes stating named as perpetrator at MARAC. If added as a Problem, this will automatically be added to the summary of problems in Patient Summary tab. Record in the consultation that information shared with LCFT regarding MARAC and patient named as alleged perpetrator at MARAC. Apply code ‘Alleged perpetrator of domestic abuse’. This will automatically be added to list of summary of Problems. This information can be requested to be not visible to Online Access and may also be padlocked with a Confidentiality Policy applied. Any feedback received from MARAC should be filed in scanned in documents but padlocked and redacted if patient requests to see their records.
2.11 Practices must protect information regarding domestic abuse from the perpetrator. If any requests are made by a named perpetrator to see GP records or the records of their children the practice must take care in redacting any information relating to the victim, children or the MARAC. GP practices should never inform the perpetrator that a MARAC is /has taken place. GP practices can apply padlocks to confidential information and can also apply physical screen privacy filters to prevent a patient seeing sensitive information during a consultation:
2.12 Any flag/alert on a record relating to MARAC should remain on the record for 1 year post MARAC.
2.13 To remove information added to a Patient Warning, double-click on the Precis bar to open/expand it and click on Manage, then highlight to required warning entry and select Delete, then click OK.
3.0 As detailed in the Principles at the beginning of the guidelines, all Summary printouts (Full or Brief) when printed will not redact any confidentiality policies applied to a care record or any information that has been hidden from online visibility. Please ensure to follow the recommended next steps to print out care record content and redact sensitive information using a User Defined Summary.
3.1 A User Defined Summary can be printed from multiple tabs within the care record. This example is demonstrating from the Consultations tab. Select the Print option on the ribbon and only choose User Defined Summary:
3.2 The Demographics tick box will be pre-populated. Select/tick the relevant items for inclusion in the print out. Do not select Problems as sensitive problems cannot be redacted!
3.4 Select/tick Consultations to include them and then click on the Filter (last 3 consultations)
3.5 From the print criteria window click Selected Consultations, then click on the browse (looking glass) icon.
3.6 At the Care Record Picker you will be able to select/tick the consultations that you wish to include in the print out, please note that the padlocked confidentiality policies that have been applied to any consultation will be clearly visible to a Doctor/Clinician as well as any hidden from online visibility. A non clinician will not have access to the padlocked information. It will not be visible or printable. A non clinician will only be able to see the hidden consultations from online visibility:
3.7 In either case, the person making the selection must do so with careful consideration of what to include/exclude from the print out. Once the selections have been made, click OK.
3.8 At the print criteria window, you will be presented with the list of selected consultations, click OK.
3.9 At the Print User Defined Summary window ensure the Problems tick box is not selected and click Print.
3.10 You will be presented with a User Defined Summary with the all the selected items, please view the content before clicking on Print. To include the Problems that were omitted from the User Defined Summary, click on the Problems tab. Please note as a Doctor/Clinician, the Confidentiality Policy (padlocked) consultations will be clearly visible:
3.11 For a non clinician these padlocked consultations will not be visible:
3.12 In either case, the person making the selection must do so with careful consideration of what to include/exclude from the print out. Select the required Problems for inclusion in the print out. You can either select the alphabetical letters beside the Problem (i.e. A, B, C etc.) or by holding down your Ctrl Key on the keyboard and individually select the required problem items:
3.13 Click on Print on the ribbon and then choose Selected Items.
3.14 You will now be presented with a report containing the patient's demographic information and a list of the selected problems only. Click Print and attach this document to the previously printed User Defined Summary.