Righting Clinical Records

[kitedoc]

In one hospital that I know of in Australia (and maybe more) there is a section of policy which states that a patient or representative may view and write in his/her health (usually) medical record during the hospital admission (A7E etc onwards). This policy arose from a Coroner's recommendation. In that sense this policy, introduced in 2006, some 6 years after the Coroner's recommendation was made, is a bright light is an otherwise gloomy and sad tale. Of course no other hospital is bound by the Coroner's recommendation, and even then the Coroner's recommendation has no obligatory power. However, if a further death occurred in that hospital , which implementation and adherence to this policy could have prevented, the insurance implications for the hospital would be daunting. However, the particular recommended section is buried within general hospital policies and not even the local Health Advocate Agency and other patient support groups were unaware of it does tend to speak volumes also.
In Oz at least I could find no legal impediment to such a policy being made , but of course bureaucracies are often driven by convenience (or reduction of inconvenience) and fear of litigation rather than what is best for patients.
What is the situation in your neck of the woods ? Could implementation of such a policy have prevented problems and worse regarding your diabetes, or that of a friend or relative? Should the same apply to GP and DSN records ? And what do you think of a different but perhaps parallel scheme in the US called OpenNotes ?

 

[DCUKMod]

To be honest, I have no idea whatsoever, although under various laws we do have the right to view our medical records (and anything else an institution holds for us, provided we go through the correct channels to request it. There are exceptions where it is believed that a person viewing their records would be seriously negatively impacted - usually where serios mental health issues/illness is in situ.

 

[kitedoc]

To be honest, I have no idea whatsoever, although under various laws we do have the right to view our medical records (and anything else an institution holds for us, provided we go through the correct channels to request it. There are exceptions where it is believed that a person viewing their records would be seriously negatively impacted - usually where serios mental health issues/illness is in situ.

Thank you @DCUKMod, we, in South Australia, have a Freedom Of Information Law that requires health consumers to jump through legal hoops to to access clinical records but to deny a patient to see his/her clinical record whilst say, in hospital, breaches patient rights. Bureaucracy at its finest.
The hospital which has the policy about reading and writing in patient records is in another Australian State where more flexible access to clinical records has been legislated. But as I wrote, the legal advice I received (actually from the lawyers of a large private hospital group with hospitals in most Australian States) was that in principle there is no legal impediment for patients to be able (in Australia) to write in their notes. Of course, writing in a designated area and not altering anything written in the record would be provisions in keeping with acceptable practices.
Already I can take along a list of medications, symptoms or whatever and ask my GP to incorporate them into my notes.
The OpenNotes system which is followed by a few well known American medical centres, is more a collaborative approach to medical records where the clinician and patient share the same side of the desk as it were so that they together can discuss whether the record is accurate, is what the patient said accurately reflected in the record. Are there any alterations, corrections required , and does this or that medical term's definition fit what the patient understands to be his/her condition etc.? Not so much a strategy for A&E but imagine the number of clinics and numbers of patients attending them and the risk of inaccuracies and misunderstandings !!.