The following is a reader take, in response to a post on whether patients should own their medical records, by an anonymous nurse.
Dear Dr. Pho,
I wish to respond to your position on patient access to their medical records both as a patient and a nurse.
If a doctor or other health professional believes their documentation would be inappropriate or too sensitive for a patient to view, he or she shouldn’t document it. I understand your concern about liability and/or difficult repercussions but if one suspects or can truly substantiate harm inflicted upon the patient or others they have the option to report it to the appropriate agency and document their concerns in that confidential report.
As a patient I make it a practice to view all of my medical records and have found significant errors. Case in point, I was seen in the ER for what seemed like a bad case of the flu but with a bizarre symptom, a reddened and edematous right leg. When my symptoms hadn’t abated 3 days later I returned to the ER only to be met with disdain and judgment by the PA as he read the results of my urine analysis. It showed an impressive array of illegal substances that I knew to be untrue and needless to say I was shocked and dismayed, not to mention the ramifications of the care received by the patient to whom those results belonged.
At the time I worked at a drug detox facility and experienced first hand the tendency of addicts to be less than truthful. So it was not surprising that my insistence that there had been a mistake was met with indifference. I insisted that they repeat the test arguing that if those results were indeed mine many of the drugs would still be in my system. Needless to say the results were completely normal, yet despite those results and affidavits from my colleagues and primary care physician, and the off the record agreement from the supervising MD, I was told that once documentation is entered into my “permanent record” it was illegal to remove it. Eventually the Chief of the ER would only concede to write in an addendum note that the results “may have” been in error.
Despite this concession I knew my credibility as a patient in subsequent visits or hospitalizations would be met with suspicion.
On a professional note, as a nurse at a well known, cutting edge medical center on it’s psychiatric unit I found a distinct difference in the tenor of our notes when patients were given the opportunity to collaborate with their nurse on their goals for that shift and were required when possible to read the end of shift note to confirm their participation and progress. Our notes took on a more professional tone that reflected objective observation, compassion for their suffering and the difficulty and promise of managing their illness.
Yes, this entailed much more time and effort on our part, but I must say it left me feeling that I made a difference in honoring and alleviating another human being’s suffering and validating the truth that they indeed had a voice and were the most important person on their treatment team. On a more practical note, this manner of documentation as a part of treatment resulted in briefer hospital stays and decreased recidivism.
In a climate where mental illness still carries significant stigma, sadly I must say among some health practitioners as well, we would do well to consider how we phrase our documentation and ask ourselves: “Would I feel awkward or in jeopardy of liability if my patient read my note?” If the answer is yes, rather than being fearful of a patient’s reaction, I would propose we take an extra moment to re-phrase our documentation.
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