Advice line dilemma - appropriate consent

A doctor who had recently discharged a patient following a brief admission was contacted by the patient's insurance company for information about his illness and treatment. The doctor, an ST1 based on a general medical ward, contacted the MDU advisory helpline because she wasn't sure how to proceed.

MDU advice

The medico-legal adviser suggested that the doctor's first step would usually be to check whether the insurance company had provided written consent from the patient to disclose this information to them. In most cases, reports to insurance companies should not be disclosed without explicit consent from the patient.

The GMC's confidentiality guidance makes clear that doctors should ensure that the patient's consent has been obtained, that the patient understood what information would be disclosed and the consequences of this disclosure.

The doctor could then provide a factual account of the patient’s diagnosis...

The doctor revealed that the insurance company had not provided written consent and so the medico-legal adviser suggested that she contact them to explain that she could only send them the information that they wanted once the company provided the appropriate consent from the patient.

With appropriate patient consent, the doctor could provide an insurance report. The medico-legal adviser suggested this should be typed on headed paper, clearly identifying the doctor's name, qualifications and position within the trust, as well as the purpose of the report and the name of the person who requested it. The doctor could then provide a factual account of the patient's diagnosis and the treatment given during the patient’s recent admission. However, the GMC guidance states that she only needed to disclose relevant information. For example, details of previous admissions for unrelated medical conditions did not need to be included in the doctor’s report.

Finally, the medico-legal adviser suggested that the ST1 doctor offer to show his report to the patient before it was disclosed to the insurance company, in line with GMC guidance.

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