Question

A 48-year-old woman is diagnosed with invasive breast cancer and is tearful in clinic. She asks you not to document the diagnosis in her medical record because she is worried her family might see it. What should you do according to GMC guidance

Accepted Answer

Record the diagnosis accurately in the medical record and explain that this is essential for safe care

Answer

Agree not to document the diagnosis to respect her wishes

Answer

Record the diagnosis using vague non-medical terms so others cannot understand

Answer

Ask her husband to consent to recording the diagnosis

Answer

Only record the diagnosis in a personal notebook rather than the official record

Practice question

A 48-year-old woman is diagnosed with invasive breast cancer and is tearful in clinic. She asks you not to document the diagnosis in her medical record because she is worried her family might see it. What should you do according to GMC guidance