Medical supervision report

Transcription

1 Medical supervision report 1. GMC case details 2. Details of the medical supervisor Case reference Your full name 3. Details of the doctor under supervision Full name Date of birth 4. Supervision appointment (since last report) 5. Report Appointment date Date of report 6. Impairing diagnosis(es) Impairing ICD diagnosis(es), if any. 7. Opinion on fitness to practise Please select

2 Introduction Health and treatment the doctor's current state of health with particular reference to the impairing condition(s) details of medication being prescribed, details of any therapeutic intervention, details of any other treatment the doctor is receiving. Employment details of current/most recent employment whether the doctor's impairing condition has affected their performance at work the doctor's career and employment plans details of any work arrangements you have approved (new posts, on-call, out of hours)

3 Relevant personal and family history details of any relevant changes to personal, occupational, social, financial and relationship history, details of any relevant changes to alcohol and substance misuse history if not covered already. Mental state examination observations on appearance and behaviour, including self-care, thought content, including self-harm, comments on insight. Physical examination details of any physical examination you carried out, comments on self-care, alcohol on breath, or visible physical signs of physical illness are relevant here, even if a physical. Important: You're not routinely expected to carry out a physical examination. However, if you think this is necessary and relevant, you should ensure that you have got the appropriate consent and follow the guidance on the use of chaperones.

4 Testing details of any testing carried out (if none, please state 'no testing carried out'), interpretation of results, explanation of any anomalies, your comments on whether current testing regime is appropriate. If you feel changes are needed, please provide details for us to consider. Important: You should refer to the chemical testing guidance. Informant history and third party evidence full details of the sources of information you consulted, details of the phone conversations, including the date and who you spoke to, any written correspondence as an annex to your report. Important: You should not contact anyone not listed on the consent form without getting the doctor's written consent. Compliance with restrictions (undertakings or conditions) details of all your appointments with the doctor since you last reported to us, confirmation that the doctor has cooperated with supervision, details of any missed appointments or failure to adhere to advice given, details of compliance with undertakings or conditions that relate to the doctor's health with any explanations provided for failure to comply with restrictions.

5 Diagnosis a current diagnosis using the ICD-10, highlighting whether the diagnosis has changed since you last reported or confirmation of no diagnosable condition. Reasoning for diagnosis Use this section to support your opinion with reasoning, supporting information and evidence. Important: You should consult the guidance on giving an opinion on fitness to practise.

6 Clinical summary This section should include the evidence or basis on which you have reached your clinical conclusion, and make specific reference to: risk of self-harm/suicide risk to others risk of relapse the doctor's level of insight into their health condition Clinical opinion Fit to practise generally Use this terminology if you believe the doctor is fit to practise medicine without restriction. Fit to practise with restrictions Use this terminology if you believe the doctor should continue to be able to work, but with limitations on their practice. Not fit to practise Use this terminology if you believe the doctor is unable to work in a clinical capacity at all. Please select your opinion on fitness to practise Use this section to support your opinion with reasoning, supporting information and evidence. Important: You should consult the guidance on giving an option on fitness to practise.

7 Recommendations Use this section to provide your recommendations about the following. Please provide clear reasoning relating to the impairing condition: your specific advice on the future management of the case (eg alterations to testing regime, prescribing arrangements, working arrangements, clinical supervision) with your reasoning, details of advice provided to the doctor regarding specific restrictions (eg abstinence, attendance at support groups, locum and on-call work) with your reasoning, summary of your recommendations for future management and supervision arrangements with your reasoning, Important: A copy of the GMC glossary of terms is here. Please refer to it when writing your recommendations. Appendix Please provide copies of additional documents from other sources, e.g. treating doctors.

8 Statement of truth 1 I confirm that I understand that my primary duty in written reports and in giving evidence is to the Committee, rather than the part who engaged me. 2 I have endeavoured in my report and in my opinion to be accurate and to have covered all the relevant issues concerning the matter which I have been asked to address. 3 I have endeavoured to include in my report those matters of which I have knowledge or of which I have been made aware that might adversely affect the validity of my opinion. 4 I confirm that there are not any reasons why the medical report should not be shown in full to the doctor. 5 I have indicated the sources of all information that I have used. 6 I have not, without forming an independent view, included or excluded anything that has been suggested to me by others. 7 I will notify those instructing me immediately and confirm in writing if, for any reasons, my existing report requires any correction or clarification. 8 I understand that: a b c my report, subject to any corrections before swearing as to it's correctness may form evidence to be given under oath or affirmation; I may be cross-examined on my report by a cross examiner who may be assisted by an expert; I may be subject to adverse criticism by the Committee if it concludes that I have not taken reasonable care in trying to meet the standards set out above. 9 I confirm that I have not entered into any arrangement where the amount of payment of my fees is in anyway dependant on the outcome of the case. 10 I confirm that insofar as the facts stated in my report are within my own knowledge, I have made clear which they are and I believe them to be true and that the opinions I have expressed represent my true and complete professional opinion. 11 I have no conflict of interest of any kind, other than any which I have disclosed in my report. 12 I do not consider that any interest have disclosed affects my suitability as an expert witness on any issue on which I have given evidence. 13 I will advise the party by whom I am instructed if, between the date of my report and the hearing, there is any change in circumstances which affect my answers to any of the above declaration. Signature Date Click here to remove the instruction fields when finished