EILIF DAHL; STEVE WILLIAMS
A.5.1 Current practice and limitations
According to the Maritime Labour Convention 2006 (MLC2006) [1], the ship´s Master must, on behalf of the flag state, ensure that seafarers are given health protection and medical care as comparable as possible to that which is generally available to workers ashore. On ships carrying more than 99 persons and ordinarily engaged on international voyages of more than 3 days duration, there will be a qualified physician. However, on most ships, the person responsible for medical care will be the Master or a seafarer designated to provide first aid and medical care on board.
In case of significant injury or illness, notes are made in the Master´s Bridge Log, and the officer responsible for medical care must enter an individual patient record on standardized forms. This ensures that all of the important medical details are recorded and can later be provided to medical care providers, whether on board or ashore, or to officials, such as port health authorities, coroners and the police if appropriate and with the seafarer’s consent. [1, 2] Based on information from the patient records and from safety investigations, the Master must provide reports on injuries and occupational illness to flag state authorities and health reports on potentially contagious illnesses and suspicious deaths to local port state authorities.
Individual patient information may also be of interest to others, including insurers, legal representatives, and ship owners. However, the Master and the officer responsible for medical care are, like medical staff everywhere, bound to observe medical confidentiality [2]. Chapter 2.9, 2.4.4 and 4.8.3 gives further information about ethics and confidentiality, but note that patient information can only be revealed to others after obtaining the patient´s informed consent or when the Master considers that the safety of the ship, others on board or the patient is at stake.
The Master is also responsible for the presence on board and the validity of other medical records for every seafarer. Examples include the pre employment medical certificates and mandatory vaccination certificates. In addition, he is responsible for ensuring that there is an accurate and up to date record of the contents of the ship´s medical chest and of all the medical lifeboat kits.
A.5.2 Best practice
General
The patient record must contain all relevant information about
- the current illnesses or injury,
- relevant past medical history, including allergies
- examination findings,
- any treatment provided, and
- requested follow-up on board and ashore.
To ensure that it contains all necessary data, the record should be based on standardized forms [1]. Forms for case reporting, referral, and evacuation can be found in the International Medical Guide for Ships, 3rd edition, Annex A [2].
All medical information about each patient should be gathered in one file, preferably on a secure computer. The record should contain the completed standard forms and all other available relevant information, for example, conversations or emails with tele-medical assistance services, referrals to shore-side practitioners and their feedback, as well as documentation regarding sick-leave, details of any evacuation and a copy of the patient´s pre-employment medical certificate etc. [2].
Cruise ships
Most vessels with ship´s doctors, such as cruise ships, carry more passengers than crew. On such ships, a regular medical record must be kept for each passenger and crew patient, and all the ship-related information mentioned above must be included. For legal reasons, the medical records must be made, and subsequently stored, according to the rules and regulations of the flag State, and of the country in which the doctor holds a medical license. This is particularly important if the doctor is an independent contractor and not an employee of the shipping company [3].
US-managed cruise ships
For doctors and nurses working on board ships owned and managed by US-based cruise lines there are additional medical documentation requirements under the current legal framework within the US. Since 2014 doctors are no longer considered independent contractors but agents of the cruise line irrespective of their employment status. This change in their legal status occurred because of the case of Franza vs Royal Caribbean Cruise Lines . that overturned the previous legal precedent set in 1988 by Barbetta vs S/S Bermuda Star [3,4]. It effectively means that cruise lines are held liable for the medical malpractice of their doctors and nurses. More information on liability is available in Ch 2.10.
In any medical encounter, the doctor must consider that in any subsequent litigation his documentation will be carefully scrutinized down to the very detail of every aspect of the medical encounter. As well as documenting actual clinical findings and the patient examination, it is necessary to document any ‘pertinent negatives’. In litigation it is often the clear documentation of the absence of physical findings or symptoms at the time of the examination that can be as important as documenting actual findings.
On most larger cruise ships the medical records are now fully computerized and may be coordinated fleet-wide through the company´s medical headquarters ashore. Confidentiality is a challenge; the computer systems must be secured to allow access only for relevant medical professionals.
A.5.3 Establishment of a database (SW)
The cruise medical sector has always been well suited for electronic medical record systems. The need to compile comprehensive crew and guest medical records across fleets of ships sailing internationally is a prime example of how technology can support improvements in clinical care. Essential criteria for such a system include:
- All entries should be dated and electronically signed. For legal reasons it must not be possible to change signed documents.
- Medical programs must ensure data security, confidentiality and privacy, and providers must guarantee 24/7 global support for all services. More information on ethics and confidentiality is available in Ch 2.9.
- The system must be easy to learn and utilise as handover time is often limited with many things to cover.
Tritan Software, which by 2020 supported approximately 95% of existing cruise lines, claims to fulfil those quality criteria [5].
References
1. International Labour Organisation. Maritime Labour Convention 2006 //www.ilo.org/wcmsp5/groups/public/@ed_norm/@normes/documents/normativeinstrument/wcms_090250.pdf"
https://www.ilo.org/wcmsp5/groups/public/@ed_norm/@normes/documents/normativeinstrument/wcms_090250.pdf (accessed 19 October 2018 19 June 2021)
2. World Health Organization. International Medical Guide for Ships, 3rd edition. WHO Press, Geneva 2007
3. Dahl E. Cruise ship´s doctors – company employees or independent contractors? Int Marit Health 2016; 67, 3: 153-158
4. “Patricia Franza vs RCCL”. The United States Court of Appeals, Eleventh Circuit. Case No. 13-13067, filed 11/10/2014. http://media.ca11.uscourts.gov/opinions/pub/files/201313067.pdf5.
5. Tritan Software. SeaCare. https://www.tritansoft.com /cruise-lines/#cl-health-medical-operations (accessed October 2018 19 June 2021)