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Can anyone tell me exactly what details on the new patient form are legally required for us to begin treatment? I ask for name, address, DOB, medical Hx, allergies, Mx and GP's name + address. Can a new pt refuse to give a medical history, then expect us to treat them? I wonder how this stands from a legal viewpoint? Also, details such as date of birth, are often refused- particularly from the women aged 50-75 -!! And no one ever seems to know what Mx they are taking :confused: Can anyone point me in the direction of which details we actually do need to cover ourselves (and them, I guess)?

 

In Australian the National Allied Health Classification Committee has developed a Minimum Data Set which is on page 9 of the linked document. It may be of help

 

Providing you record the refusal to disclose information and 'no harm' can be done in your considered opinion, it is ok to proceed, but if in any doubt you are obliged to refuse to treat. I could validate this with references if required.

jude

 

Thanks, I'd be interested to look at those refs.