19 April 2011

Q. Working as a hygienist treating many senior citizens I am sometimes worried about the accuracy of the medical history that I receive from the patients particularly if they are on anti-coagulants. Do I need to see a copy of their most recent INR (international normalised ratio) or is it acceptable to rely on the information that has been ‘remembered’ by the patient? Many of them seem a little vague and I wonder if I can rely on what they are telling me. I don’t want them to bleed excessively after my treatment.

There is an ethical responsibility for all clinicians to treat patients as safely as possible. This obviously includes a detailed knowledge of the patient’s medical history.

As the treating clinician it is your decision as to whether or not the information being provided by the patient is accurate enough to enable you to provide safe treatment. If there is any doubt, in order to act in the patient’s best interests, you should ask to see documentary evidence. If the treatment is urgent or the patient is unable to easily produce the latest blood test result, you could also request their consent to allow you to contact their medical practitioner in order to obtain this information.

This online resource provides information on bleeding disorders as well as providing the normal values for a variety of standard medical tests.

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