Friday, January 10, 2014

Whose Medical Record Is It Anyway!

A recent article in the prestigious New England Journal of Medicine discusses the usefulness of giving patients full access to their medical records, including the physicians "notes," which had previously remained inaccessible.

A medical record includes laboratory results, radiology results and pathology results - all of which I concur should be made available to a patient - after all, they are his lab results, his radiology results, and his pathology results.  However,  it had always been my feeling that what I entered into a medical record (my "notes") was only for my eyes and for other eyes to which I wished to show them.  And when I translated these notes into a formal letter, most commonly to a referring colleague, the letter was a private communication between my colleague and me.

Medical record "notes" often contained personal reflections on the patient, possibly his family, his attitude, and maybe even some quirky anecdotes to help recall a a previous encounter.  I never regarded my "notes" like those that would be part of a personnel record or subject to the Freedom of Information Act.

But I guess those are bygone days.  Now, were I to enter information into a patient's record - it would be limited to "the facts." Any "color" would have to be withheld from the written record and restricted to some non-written form of communication (if deemed necessary).

Progress - onward and upward.

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