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Re: Medical Records

Posted by Elizabeth on March 24, 1999, at 21:46:49

In reply to Re: Medical Records, posted by Toby on March 23, 1999, at 15:39:44

It seems people are getting the idea that it's generally okay for a therapist, without any particular justification, to deny a patient access to his or her medical records. It's not, and it may even be illegal, depending on where you are.

The law in Massachusetts on this depends on the practitioner involved. A private hospital must provide a copy of the record to the patient or the patient's representative (legal guardian, etc.) (although they may charge a *reasonable* fee for it). A state hospital is only required to make the record available to a patient under certain specific circumstances (e.g., the patient is suing the hospital). A private therapist must give the record to the patient unless the therapist has made an honest and specific judgment that it would be harmful to do so (for some particular reason). In this case, the therapist still must provide a copy to the patient's attorney or a psychotherapist of the patient's choosing, and also give the patient a "summary" of the record.

Toby says:

>Paternalism and ethics are not mutually
>exclusive concepts. Paternalism is
>defined as doing something for someone's
>benefit without that person's consent.
>This is the concept that governs
>guardianship, parenting, and involuntary

More precisely, paternalism means doing soimething that you believe is for someone's benefit that is *contrary to their wishes*, not simply without their consent. It should be regarded as a necessary evil, not something to be practiced on a whim.

The examples you give are acceptable only because the people who are having decisions made for them are considered incompetent to make the decisons themselves, by virtue of age or mental status. You cannot simply assume that any person who has at some point been a psychiatric patient is therefore mentally incompetent.

>With regard to allowing a patient free
>and unsupervised access to their
>psychiatric record, there is obviously
>a paternalistic aspect since the therapist
>is presumed to have knowledge that the
>patient may be incapable of understanding
>or, in the therapist's judgement, may be
>better off not knowing, but as Dr. Bob
>said, ethics would dictate that if the
>record is opened to the patient, the
>therapist should be present to discuss
>those issues with the patient.

Umm. Certainly a therapist (or a medical doctor) ought to *offer* to go over the record with the patient. This is a different question than whether it is justifiable to withhold the record from the patient altogether or to *insist* on reading it with the patient.

>The previous statement may offend
>many who read it here, since most
>folks who can operate the internet
>are fairly well educated and believe
>that they know just as much as any
>therapist or psychiatrist when it
>comes to their own mental illness.

Most of us know what we don't know, actually.

In any case, a psychiatrist (or "therapist") ought to be held to the same ethical standards as any other health care practitioner. If anything, psych records are easier to read than other medical records, so I really do not believe this argument holds water.

Since you seem to need a reason why anyone would want to see their records, here's an obvious one: for many people with chronic illnesses, understanding the illness intellectually is a coping mechanism. (A healthy one, at that, as long as it doesn't grow into an obsession - wanting to read one's own medical records is not, IMHO, an obsession.) Nothing to do with juicy details.

Insurance companies often ask to see patients' medical records. I find it hard to believe that, in general, you think it's perfectly fine to show something to an insurance company that you can't show to the patient. Many therapists don't even keep detailed records (much less records containing what might appear to be "malicious gossip"), out of respect for confidentiality, for the patient's privacy (they don't want the HMO to be reading all about a patient's personal life, and maybe they also don't want to have a document that can be subpoenaed by a court of law). They note a diagnosis, treatment plan, and their justifications for same, but little more than that beyond keeping track of progress and changes.

There's something I don't get: if something is too embarrassing for you to tell a patient, why put it in the record, a legal document, and not, say, your personal diary? (If embarrassment is not what you hope to avoid by withholding a record from a patient, you may wish to provide an example of something that would be harmful for a mentally competent patient to read and that you would put in his or her medical record.)

As a side note, I've read some of my own records. I've never come across anything that looked remotely like "gossip" (and no, this is not just because my life is boring!). I can't think of any circumstance in which it would be necessary to write a psych record in a way that would sound like malicious gossip. If you can, feel free to provide an example of this also.




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