There is a potentially offensive comment in the notes of a patient who is requesting a copy of their records. What should you do? Our expert advises.
When a patient requests a copy of their medical records you need to ensure that their written consent has been provided. Access to a patient’s record can only be denied if disclosure could cause serious physical or mental harm to anyone or would disclose information relating to or provided by a third party who has not consented to that disclosure.
Although reading these notes may be upsetting to the recipient, and embarrassing for the author of the comments concerned and the practice, this would not constitute serious harm.
Unfortunately although this disclosure may put the author of the comments in an unpleasant position, it is necessary under the provisions of the Data Protection Act. This dilemma should be a timely reminder to other doctors in the practice that only relevant clinical information should be included in patients’ records as they are ultimately disclosable to the patient and also regulatory bodies.
Dr Sarah Townley is an associate medicolegal adviser at the Medical Protection Society
Credit: Simon Steiner, Flickr Typing