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Dilemma: Patient record contains distressing details

A 21-year-old asks to read their medical record.

She has previously suffered from stress and became upset when your GP colleague asked her how she was managing, although her presenting complaint (and the one with first) had been something else.

On checking her notes, you see an entry about her unusual behaviour last term, based on a telephone conversation with her college counsellor. However, this was simply a piece of information for her GP, and you are concerned that might prove distressing for her to read.

How should this be managed?

If I were a patient I would not want to have a communication entered into my records that I was not aware

richard fitton online

For 20 years I have written on my letters to hospitals that it is my practice to share correspondence with patients. My practice has 600 patients that have access to their electronic contemporary medical records, and if I were a patient I would not want to have a communication entered into my records that I was not aware. I would also wish be informed of a communication from a third party that referred to myself being entered into my records. It is uncommon to receive communications about patients that are unsolicited of which the patients are unaware, but I generally deal with such a communication by asking the patient to attend to discuss the issues within the communication.

I try to do this in a diplomatic way, referring to past issues related to those within the communication. If there are no past references I try to find another reason to interview the patient that does not compromise the third party. If I do not believe the communication or feel that it should be ignored, I do not enter it into the patient’s notes.

If someone else had entered the communication into the notes, I would firstly ask the author if I could share the communication with the patient. If they said I could share the comunication, I would. If they said that I could not, I would feel disappointed that the issue had not been sorted out at the receipt of the communication. I would feel obliged to share the contents with the patient, but not the details of the author.

Dr Richard Fitton is a GP in Glossop, Derbyshire, and a Caldicott Guardian.

Try to view this as something positive, not adversarial

david watt online

The first thing a request like this generates in GPs is anxiety.

Why does the patient want to look at their notes? Have we done something wrong? Is it a fault in us that made the patient ‘upset’?  Why is it such a worry that some information from her college counsellor might be bad for her to see? Is she psychologically or mentally ill? Or just curious, unfamiliar with a GP who asks about her general wellbeing, and anxious about her medical record? 

Try to view this as something positive, not adversarial. Access to the notes should be with a doctor, preferably one in the practice who knows the patient, perhaps the one who recently saw her. Let the patient lead the discussion about her record as she looks at it. Try to understand what this particular patient wants.

The points I would see as important for her to confirm are that: the record is confidential; the counsellor would only have communicated in the patient’s best interests; if she does have any problems with college work, information would only be of benefit; and that employers in the future do not have access to confidential medical records (making sure that the information has not been put in a summary entry).

If she is not content one might offer to ‘hide’ the note with increased security, but explain why you would be unhappy to remove it (unless with consultation with the relevant medical defence body). I hope that the meeting would be productive in mutual understanding, though if our biggest fear is realised - that she is suffering from early severe mental illness - this might not be possible. The GP would have to hold their anxiety and the patient’s unhappiness, knowing that they had not done something wrong.

Dr David Watt is a GP in Hackney, east London, and the vice president of the UK Balint Society.

It is not enough to refuse someone the right to see their records on the grounds that they may become upset or angry

Bridget O'Connell MIND online

The Data Protection Act 1998 gives people the right to see their own health records, a request that should be made in writing. Access to health records can be refused if disclosure would be ‘likely to cause serious harm to the physical or mental health or condition of the data subject or another person’.

Mind is concerned that this particular provision may be over-used in response to requests from people with mental health problems. The key thing to bear in mind here is that the test is ‘likelihood of serious harm’. It is not enough to refuse someone the right to see their records on the grounds that they may become upset or angry. If you consider there is a real likelihood of harm, you must consult with the person most recently responsible for the patient’s clinical care in connection with the data requested.

There are rules around disclosing information supplied by a third party, which in this case is the college counsellor. If the counsellor is a health professional with care of the patient, then disclosure can take place without obtaining his or her consent. A college counsellor would generally make clear at the outset that they were writing to the GP.

If you do give her access to her records, make sure she is aware that she has a right under the Act to have the notes amended if they are factually inaccurate. If the patient disagrees with a matter of opinion, it is good practice to record this. If you are concerned that the records might upset her, offer to talk her through what is written and answer any questions she may have.

Bridget O’Connell is the head of information at the mental health charity MIND.

What would you have done in these circumstances? Do you agree with the panel’s advice?

 

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Readers' comments (1)

  • If I felt my GP was withholding information from me, no matter how upsetting it might be, i would start to question why and my relationship with a trusted GP would be damaged. I would then suspect that there are other things on my record that I am not being given access to.

    Mental health patients are entitled to a copy of their report after each visit. The minute you star hiding things the relationship is damaged. Doctors should write factual information, not just their own feelings about a patient, which may not be correct!

    Medical records are about one individual, good or bad, a patient has a right to know what is being said about them!
    If a doctor has any concerns about that, they need to questions their own beliefs / practice?

    Mental health patients can probably tell a doctor more about their own risks than the doctor may be aware of, please don't under estimate their ability to understand what is going on around them and the risks they pose!

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