Exam Pass Notes

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Core Principles

• The patient is the primary focus in all contacts from relatives, carers or advocates.
• Being involved does not automatically give someone the right to receive clinical information.
• Confirm identity, consent, proxy access or other authority before disclosing information.
• Only share information that is necessary and permitted by the patient or by law.
• If you are unsure, escalate the query rather than guessing.

Proxy, Parents and Advocates

• Proxy access is explicit permission recorded in the records and may be limited in scope.
• A proxy user may be able to perform some actions while being denied access to certain notes or results.
• Handle young people's consultations and sensitive topics with particular care for confidentiality.
• Advocates help represent the patient's views; they do not automatically make decisions unless authorised.
• Seek assistance when the person's authority, the patient's capacity, or the scope of access is unclear.

Carers and Safety

• You can accept information from carers even when you cannot share patient details with them.
• Record and pass on carer reports of deterioration, medication issues, confusion or safety risks.
• Escalate suspected coercion, unsafe contact, contradictory accounts or safeguarding concerns.
• Avoid leaving messages or sharing appointment details when you cannot confirm a safe contact method.

Records and Systems

• Log who contacted the practice and the reason for the contact.
• Document what authority or consent you checked and how it was verified.
• Note what information was received, what was shared, and what information was refused.
• Record any escalation steps and who will take next action.
• Follow local procedures to change consent or to update proxy access on the record.