| Unit.C.4.4.
Documentation/Medical Records/Confidentiality |
| [Unit.A.4.4.]
[Unit.B.4.4.] [Unit.C.4.4.]
[Unit.D.4.4.] [Unit.E.4.4.] |
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Canada |
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International |
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United Kingdom |
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"Historically,
psychiatric records have been secretive and their access
denied to patients. As recently as the mid 1980's, a Committee
of the Royal College of Psychiatrists, responding to the
Department of Health and Social Security's consultation
paper on the Data Protection Act, recommended against access
to personal health data for psychiatric patients" (Prist,
1986; Slaney & Vaughan, 1998, p. 225).
"Subsequently
the Access to Health Records Act, 1990, gave all patients
rights of access to their own manually held health records,
recorded since 1991" (Slaney & Vaughan, 1998, p.
225).
"Further
more since the advent of the Care Program Approach in 1991,
a spirit of openness has developed and it is increasingly
common for mental health professionals to share their assessments
and care plans with their patients" (Slaney & Vaughan,
1998, p. 225).
"It is
probably prudent, however to take note of the clause in
the Access to Health Records Act 1990 which specifies that
health professionals can deny patient access to their records
if 'serious harm to the physical or mental health of the
patient or any other individual' would be caused" (Slaney
& Vaughan, 1998, p. 226-227).
"Results
of the study showed a positive therapeutic effect and patients
welcomes the opportunity to use their assessment report
as a therapeutic tool" (Slaney & Vaughan, 1998,
p. 226-227).
"A desire
to demonstrate good quality care placed record keeping high
on the agenda. The outcome of an audit, which focuses on
how the multidisciplinary team functioned, recommended joint
record keeping"(Yates & Deakes, 1998, p. 204).
"To address
this finding, changes is practice were implemented. Re-audit
showed that the new practice has brought the professionals
closer together and increased communication with patients"
(Yates & Deakes, 1998, p. 204).
United States |
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"Meticulous
documentation provides evidence that something is done or
is not done, exists or does not exist. Scrupulous documentation
provides protection for the nurses, evidence for a client
and testimony for the court" (Goll-McGee, 1999, p.
12).
"The Medical
Records Confidentiality Act of 1995, established appropriate
guidelines to be used by health care trustees for protection
of privileged and confidential information pertaining to
an individuals state of health" (Lamb, 1997, p. 16).
"According
to the Medical Records Institute, 1995, an electronic health
record is a computer stored collection of health information
about one person, linked by a personal identifier such as
a social security number" (Lamb, 1997, p. 16).
"Higher
levels of electronic record keeping are differentiated by
the methods of data generation, method of data storage,
arrangement of data within the computerized system, level
of interaction for data base users, number of traditional
providers for (e.g. physicians, dentists) and access to
the data base, and the amount of non traditional information
that is included (e.g. drug use diet, exercise)" (Lamb,
1997, p. 16).
"The American
Medical Association's "Opinion and Standard for Confidentiality"
is available through an internet publication called "The
Health Law Resource" http://www.netreach.net/~wmanning
(Lamb, 1997, p. 16).
"Privileged
communication is conversation that takes place within the
context of a protected relationship, such as that between
husband and wife, priest and penitent, or doctor and patient
(Loecker, 1998, p. 14).
"A matter
that is kept secret between two or more people is considered
confidential. Many businesses, such as banks, credit card
companies and stockbrokers may want to keep their client's
information confidential, but a court of law could cause
them to reveal this information if it is relevant to a court
proceeding" (Loecker, 1998, p. 14).
"Nurses
learn at the beginning of nursing school that patients have
rights to confidentiality. However, even though relationships
between physician and patient are privileged and their conversations
are generally protected from discovery, the privilege is
waived when the medical records are used to prove a claim.
Waiving the privilege, however, does not mean that the patient
waived the right to confidentiality" (Loecker, 1998,
p. 14).
"When medical
records are used to prove or disprove a negligence claim,
the client has the right to expect that they will be used
for only that purpose" (Loecker, 1998, p. 14).
"Legal
Nurse Consultants (LNC's) review medial records as part
of their routine practice, and they have a professional
duty to protect the confidentiality of those records"
(Loecker, 1998, p. 14).
Focus Points
Reference
Goll-McGee, B.
(1999). The role of the clinical care nurse in critical
care. Critical Care Nursing Quarterly, 22 (1), 8-18.
Lamb, D. L.
(1997). Confidentiality of medical records, Part II: Electronic
patient records. Journal of Legal Nurse Consulting, 8
(4), 16-17.
Loecker, B.L.
(1998). Attorney-Client Privilege and confidentiality. Journal
of Legal Nurse Consulting, 9 (1), 14-15.
Slaney, M. &
Vaughan, P.J. (1998). Patient access to psychiatric assessment
reports. Psychiatric Care, 5 (6), 225-227.
Yates, M. &
Deakes, C. (1998). Introducing multidisciplinary record
keeping in a forensic setting, Psychiatric Care, 5 (6),
204-207.
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C - Forensic Nursing > Section C.4.0. Forensic Practice/Prevention
> Unit.C.4.4. Documentation/Medical Records/Confidentiality
