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National Ethics Teleconference
Ethical Considerations of
Patients’ Requests to Have Their Health Records Amended
May 31, 2006
Good day everyone. This is Ken Berkowitz. I am the Chief of the Ethics Consultation Service at the VHA National Center for Ethics in Health Care and a physician at the VA NY Harbor Healthcare System. I am very pleased to welcome you all to today's National Ethics Teleconference. By sponsoring this series of calls, the Center provides an opportunity for regular education and open discussion of ethical concerns relevant to VHA. Each call features an educational presentation on an interesting ethics topic followed by an open, moderated discussion of that topic. After the discussion, we reserve the last few minutes of each call for our 'from the field section'. This will be your opportunity to speak up and let us know what is on your mind regarding ethics related topics other than the focus of today's call.
In today’s presentation, we will examine our ethical responsibility to maintain complete and accurate health records. We will provide practical advice to staff on appropriate health record keeping. We will also cover four specific issues related to patients’ requests to have their health records amended. By amendment, we mean the alteration of health information by modification, correction, addition or deletion. The four issues we will address are:
Procedures that a patient must follow to request that his or her health record be amended;
Standards that the Privacy Act requires for review of such requests;
Ethical factors to consider when reviewing requests for amendment; and
Implications for local facility practices regarding health records.
Joining me on today’s call are Barbara Chanko and Susan Owen.
Barbara Chanko, RN, MBA – Medical Ethicist, Ethics Consultation Service and Coordinator for the IntegratedEthics Initiative, National Center for Ethics in Health Care
Susan Owen, PhD – Medical Ethicist, Ethics Consultation Service, National Center for Ethics in Health Care
Barbara, can you begin by discussing the purpose of the health record?
Sure Ken. The health record is the legal representation of all care provided and a communication tool that has many uses. It provides documentation of a patient’s health history, including the illnesses, diagnoses, treatment, and the plan for continuity of care for the patient. The health record documents communication that occurs between health care practitioners and provides a chronological account of the patient’s health status. It also supports medical claims and billing. The information in the health record is also used for quality improvement, approved research, education and planning. In the Third Edition of Medical Records and the Law, Roach categorizes four types of data that a health record includes: personal, financial, social, and medical.
Requests for amendment may relate to any documented information, such as: progress notes, discharge summaries, consult notes and comments.
Barbara, what are the professional obligations health care practitioners have related to health records?
Health care practitioners must assure that health records are accurate and complete. The Privacy Act, 5 U.S.C. 552a (e)(5), requires that agencies “maintain all records which are used by the agency in making any determination about any individual with such accuracy, relevance, timeliness, and completeness as is reasonably necessary to assure fairness to the individual in the determination.”
These features seem to sum up the basic requirements of the health record: it must be accurate, relevant, timely and complete.
That’s right. The ethical principles of respect for persons and beneficence support this requirement. The health care practitioner respects the dignity of the patient by carefully recording what may be highly personal and sensitive information, and contributes to the patient’s ongoing care by providing a record on which other health care professionals may rely.
What endures is a record of what patients tell clinicians and what the clinician thinks, observes, and does. Of necessity, clinicians must condense, translate, and interpret information that may be involved and complicated. In every encounter, the patient trusts the clinician to record such information fairly.
The provider is always obligated to guarantee that the patient has a fair record. Why raise this issue now?
Well, for one thing, we know that there are ethics quality gaps in this area. That is, disparities between current practices and best practices. Another is that several recent changes have occurred in the management of health information:
increased development and use of electronic records. VA is getting a lot of positive press in this area
increased ease of access to such records
increased exercise by patients of their right to review and amend their records
the widespread copying and pasting of notes that multiplies information in the health record. In fact we had a NET call on that topic in February 2004
requests received by our office from the Office of the General Counsel to analyze patients requests to have their records amended; and
reports by local Privacy Officers that they are handling many requests to amend patient’s records.
For all of these reasons, ensuring the accuracy and integrity of the patient’s health care record has perhaps never been more important.
Finally, there are many more people with authorized access to a patient’s health record than you might think. According to Laurinda Beebe Harman, in the second edition of Ethical Challenges in the Management of Health Information, “in 1982, Mark Siegler, a physician and ethicist, responded to a patient’s privacy concern by counting those health professionals and hospital personnel who had authorized access to the patient’s medical record. He came up with the number of 75 – and this was in a predominantly paper environment.” The number is probably orders of magnitude higher today.
Barbara, you alluded to an increasing movement toward patient review of his or her own record. Currently, who owns a patient’s record and who has access to it?
According to VHA Handbook 1907.1, “Health Information Management and Health Records,” “the health record and the health information within the health record are property of VA, as specified in statute and regulations such as the Privacy Act of 1974 and HIPAA.” The same handbook describes who has access to health records and the ethical reasons for limiting such access. “Access to health records and health record file areas is limited to authorized personnel. Only authorized personnel are allowed to print extractions from the electronic record or to make copies from the paper chart.” The ethical principle of patient autonomy – and the related requirements of privacy and confidentiality -- support policies that limit access. Beyond that, in order to respect the dignity of the patient, the integrity and reliability of the record must be maintained.
VHA Handbook 1605.2, “Minimum Necessary Standards for Protected Health Information” provides guidance on how to determine who has authorized access to protected health information.
VA patient health records fall under the Privacy Act System of Records, 24V19 and the HIPAA Privacy Rule. The Privacy Act provides specific rights to the individual’s personally identifiable information, including the right to request amendments.
We’ve discussed general characteristics of patient records and ethical principles that support the patient’s right to have a record that fairly represents his or her circumstances and health needs. If a patient believes that this is not the case, it is logical that there is some means by which they can ask for an amendment. Barbara, can you tell us from a policy standpoint, when can the patient request to have his or her health record amended?
Under subsection (d) of the Privacy Act and section 164.526 of the HIPAA Privacy Rule, a patient has the right to request that his medical record be amended if he or she believes that it contains information that is not accurate, relevant, timely or complete. Handbook 1907.1 defines an amendment as “the alteration of health information by modification, correction, addition, or deletion.”
This doesn’t mean, however, that all requests for amendment will be granted. VHA Handbook 1605.1 Para 8g. outlines how to process an amendment denial and the rights the individual has in relation to such a denial. The Office of General Counsel for the Department of Health and Human Services recently advised VHA in writing that the HIPAA Privacy Rule requires that at the time of the initial decision by the facility not to amend the patient's medical record as requested, VHA must notify the patient of the right to file a statement of disagreement. This is a significant change from the current practice of notifying the patient of the right to place a statement of disagreement in the file only after they have exhausted all of their appeal mechanisms.
It is unclear at this time how VHA will respond to this letter. As we understand it, this will require VHA to review its current policy on insertion of a statement of disagreement and provide implementing guidance to the field.
However, the take home message is: if a request to amend is denied, the patient still ultimately has the opportunity to file a statement of disagreement in his or her record.
And I’d like to reiterate what Barbara just said that although there is some policy flux, potentially, in how this will actually occur the take home message is that if a patient’s request to have their record amended in denied the patient still will ultimately have the opportunity to file a statement of disagreement into their own health care record.
Barbara, how does a patient ask for an amendment to their health record? Must the request be in writing?
Yes, the patient must make his request in writing to the Chief of Health Information Management (HIMS) or the Privacy Officer at the facility. The patient must be very specific in regards to what he wants amended. The Chief of HIMS or the Privacy Officer will meet with the provider/author of the note and discuss the changes that are being requested. The author of the documented information in question makes the determination to approve or deny the request
What must the patient seeking amendment include in this written request?
The patient must identify what information in the health record is in dispute and the reason why. According to the Privacy Act, the patient needs to state what information he or she believes is inaccurate, irrelevant, untimely or incomplete and be as specific as possible.
Earlier you mentioned that the Ethics Center has been consulted. Tell us more about that.
We have been referred a few cases when ethical issues seemed especially prominent. Here as with all consult requests, we identify ethical factors and principles that the requester should consider in addressing the ethical question or concern that brought the case to our attention. Of course, if local Privacy Officers identify ethical concerns, we hope that they would bring them to the attention of their local ethics program staff.
Thank you, Barbara. Let’s now turn the discussion to reasons why patients ask to have their health records amended. Susan…
Well, there can be many reasons why patients may ask to have their health records amended. In all of the cases referred to the Consultation Service, the patient apparently believed that the disputed entries contained highly personal, potentially damaging information that was not timely, accurate, relevant, or needed for completeness. Although we cannot know whether these or similar entries would in fact damage the veteran, we know that patients are often deeply troubled about such entries.
What specific types of reasons might patients give for asking that their records be amended?
Sometimes patients may argue that the disputed information was gathered through procedures that did not meet ethical or policy standards. If proper procedures are not followed, the reliability of outcomes cannot be guaranteed and the principle of pure procedural justice is violated.
We know of a request for amendment that related to a failure to obtain proper informed consent for a urine toxicology test.
What are the ethical considerations that should be looked at in a case such as an improper urine toxicology test?
Competent patients have the right to accept or reject all proposed treatments and procedures. The principle of respect for autonomy and VHA Handbook 1004.1 support this right. In our example, let’s say toxicology testing was added to the more routine urinalysis without the patient’s knowledge. The tenets of informed consent would be violated as the patient was not provided information that a patient in similar circumstances would want to know, including what tests would be performed, the risks and benefits of the test, alternatives, and the choice not to consent.
So in this example, many of these responsibilities with respect to informed consent were not carried out.
Yes, that’s correct.
Barbara, how would a case like that be resolved?
Our consultation service response to the Office of the General Counsel indicated that the patient’s request for amendment appeared ethically justifiable.
This was based on the determination that the ethical principles of respect for autonomy and nonmaleficence were violated, and the Privacy Act standards of relevance and accuracy were not met. Another interesting facet of this case is that the patient was a known chronic substance abuser, and he was aware that his record contained other documentation of substance abuse. Given this history, the positive urine toxicology result might not have the potentially harmful effect that it might for a person who had no previous documentation of substance abuse in his or her record. Despite this, it is important to note that failure to obtain informed consent for the specific test cause the patient to feel that his or her rights were violated, even if the test result contained no new information.
The patient objected based on principle. It’s important to recognize that this can occur in any service in the facility. And patients really sometimes feel very, very strongly about the accuracy of their records.
Barbara, can you describe another reason why patients might want to amend their health records?
Let’s again consider urine toxicology screening as a hypothetical example. But this time let’s think about a patient who places his urine sample, which happens to be unlabeled, on a table with other samples. When the test comes back positive, the patient asserts that his test should have been negative, and feels that the specimens must have been mixed up when they were taken from the table for labeling. Although this was a failure in process, the disputed test result was the basis for the amendment request.
In this case adequate chain of custody procedures were not followed. The patient is justified in having misgivings about the custody and proper identification of the sample, and hence the results. If proper procedures are not followed, the patient may fail to trust not only his or her individual results, but the system as well. Moreover, if this particular result was unreliable, what does this suggest about the reliability of the other test results for patients who were tested at the same time? This type of situation may represent a patient safety problem and the Patient Safety Officer might want to consider the ramifications for other patients who had testing at that time.
Paragraph 7.f of VHA Handbook 1106.1 states that “standards, procedures, and policies” be “developed for reporting of timely, accurate, reliable and clear test results”. Correct patient identification must be ensured and “the testing site must ensure optimum integrity of the specimens from the time of collection until testing has been completed, and the results reported” (Handbook, 1106.1, Paragraph 7.f3ab).
If, for example, specimens for drugs of abuse are collected, a written “specimen collection and identification policy” must be in place and Federal regulations for collection and specimen management must be followed. Among other stipulations, policy must address “validity of specimen and person, chain of custody, and security of specimen” (Paragraph 7.f 2bcd)
And I would add that in a recent article in the Bulletin on Narcotics, Kapur (2005) states that “the urine specimen and the custody document be under the control of the collection site person” and provides an ethical rationale for such policies. The potential economic, psychological, familial and medical harm to the patient of a “positive” toxicology test are significant. Given potential effects on patient welfare, the local facility bears the burden of demonstrating that transparent written procedures regarding chain of custody are in place and followed.
That’s right Ken. And in this example, no such procedures were in place or followed.
And as in the first example, under the Privacy Act, 5 U.S.C. 552(a)(3)(5), the standard of review for amendment of records is whether such records are accurate, relevant, timely and complete to assure fairness to the individual in making determinations about the amendment. In this example, the accuracy of the test is in question and thus fairness to the patient cannot be assured. The absence or breach of procedures in the facility should not impose an unfair burden on the patient, and the risk of harm to the patient is not ethically justified.
Yes, that is correct.
So, in each of these examples, the ethical considerations should be how to balance the integrity of the health records with the patient’s right to appeal the information that he or she believes is inaccurate or incorrect. In the examples we discussed, the patients’ requests seemed ethically justified and the Office of the General Counsel decided to grant the requests for amendment.
We also considered examples where we would not believe that the request, from an ethical perspective, was justified. Consider another scenario, say one where the clinician felt the patient was threatening, and called facility police. The patient requested that entries in his health records “with respect to alleged threatening behavior and remarks” be removed, based on the claim that entries involved are “false” because the clinician involved “ceased to be an impartial physician at the time she caused the police to come to my bedside.”
In this situation, the record described significant differences in how the patient and clinician perceived and understood the situation. Differences in perception alone do not ethically justify removal of the disputed entries. VHA is deeply committed to developing and implementing policies that protect the rights and needs of patients. Among these are the right to refuse treatment; the need for adequate continuity of care; and the right to health care records that can be relied upon to make “determinations regarding proper and necessary medical care.” The care team needs to record events, including their perceptions of events, accurately. We believe that the disputed clinician entries in this scenario should remain intact since they accurately reflected the clinician’s perception of the events.
Getting back to something that we talked about earlier, given the widely different perceptions of the patient and clinician, is there any way - besides amendment - for the patient to make his views part of the permanent record?
Yes. While we believe that the disputed clinician entries in this case should remain intact, we do not believe that any fundamental ethical principle would be violated by allowing the patient, within the limits of policy, to add a brief statement of objection to his health care record. In fact, this is an option specifically offered.
We have discussed the purpose of the health record; the processes patients must follow in order to request amendment of their records; some reasons that patients might request amendments; and ethical considerations for local and national Privacy Offices to weigh as they consider these requests. What additional ethical issues should those who write in health records consider in order to meet the standards of relevancy, accuracy, completeness, and timeliness?
Peoples’ lives, and how they perceive the health care system, may be influenced by the contents of their health record. Although we go to great lengths to protect the personal information of our patients, the fact remains that many people have authorized access to the health record.
Does the literature recommend best practices for documenting sensitive personal information?
Yes, Ken. There are ways to document sensitive information that can convey the needed clinical information without unnecessary, subjective comments or interpretations, and it is incumbent on practitioners and facilities to become more educated in this area. Discussing “hostile” patients, for example, William Roach, in the third edition of Medical Records and the Law, writes: “A health record should contain remarks concerning the patient’s hostility only if such conduct is clinically relevant; in those cases, notations should be limited to concise descriptions in clinical terms.”
And I think in general, that is sort of the take home message. That sensitive information needs to be conveyed if it’s necessary clinical information but it should be done so without unnecessary, subjective comments or interpretation.
What additional steps can individual clinicians or local facilities take to honor the autonomy of patients as health information is disclosed and yet preserve the integrity of patients’ records as such information is recorded?
Clinicians should help educate patients about how far confidentiality and privacy extends. In “A Qualitative Study of Women’s Views on Medical Confidentiality” (Journal of Medical Ethics, September 2005), Jenkins, et. al. concluded that although patients in this study “shared a basic understanding of confidentiality as protection of information,”some might have their own “medical confidentiality models.”
In addition, as we’ve already mentioned, facilities should make sure that testing protocols meet ethical standards for informed consent and procedural requirements such as proper chain of custody and that health record entries meet the Privacy Act standards of relevance, accuracy, completeness, and timeliness.
The examples of record amendment requests that we discussed concerned information that is commonly accepted to be highly personal. It is important to conclude by broadening the discussion. It is likely that all of us and those we care about have health records. The ethical imperative to represent the patient fairly is universal.
In an essay in The New York Times on May 9, 2006, entitled “The Quest for Privacy Can Make Us Thieves,” Columbia psychiatrist and author
Robert Klitzman describes a particular striking example of how far one woman went to protect her own privacy and that of her children. He writes:
"I stole it for my kids' sake, so they will be able to get insurance.” The woman had secretly removed pages from her [paper health] record, tucked them into her pocket and left the clinic. Those pages contained information showing that she was at risk for Huntington's disease. She was concerned that the information, once in the health record, would be seen by insurance companies and that her children might then be denied insurance in the future.
Klitzman wondered how often such pilfering went on — and whether it would increase in the new age of genetic information. Increasingly, savvy patients are wary, and they are talking with physicians about whether genetic data and other highly personal health information should be included in the record and how it should be done.
The patient felt that the only privacy one can have is the privacy you make yourself. Klitzman hoped that that would not always be the case.
We must continuously recognize our responsibility to maintain accurate, timely, relevant and complete records. Each entry we make must meet these standards. All of us must realize that we hold the patient’s information in trust, and we can never be too careful about how we guard it.
Well I’d like to thank Ms. Chanko and Dr. Owen for discussing the topic of Ethical Considerations of Patients’ Requests to Have Their Health Records Amended.
Now that we have had an opportunity to discuss this topic, I would like to hear if our audience has any response or questions.
Laura Green, Lincoln, NE:
Sometimes we are told that the provider has to okay a change. Now I know there’s a difference in actually changing a record and the patient amending the record. Using your example of the hostile patient and the police were called, it doesn’t need to be approved by the provider for that patient to add their comments to the record. Is that right?
Well we do have colleagues from the Privacy Office and Office of General Counsel on the line. But it is my understanding that the locus of decision making with the request for amendment does fall with the author of the note.
Okay, so they do have to say that it is okay with them for the patient to add their comments.
I believe that is correct.
Raymond Konz, Milwaukee VAMC:
In CPRS, if you’re deleting a progress note because of error, in the hard copy, you wrote error and initialed it. Can you delete a progress note because of error or are you supposed to write an addendum to it? Or can you hit delete progress note and then a note comes up, are you deleting because of an administrative act or privacy act, I’m not really clear on that.
Stephania Putt, VHA Privacy Office:
It terms of being able to use the amendment functionality in TIU (text integrated utility) for the progress note, when you’re doing an amendment, an actual privacy act amendment, when you come to where it says is this administrative or is this privacy, follow the privacy options. And there may be someone from Health Information Management that might be able to give you more details in that regard.
Caller, Buffalo, NY:
You’re exactly right. There are two separate issues here. One is amending the record – and that is done by the privacy officer. And the other is deleting an error, thereby deleting the note, and that is an administrative function. We do encourage that you put an addendum on for the specific author who is requesting that the note be deleted, put an addendum on the note identifying it because once it’s deleted it becomes a retractable note which is also discoverable. So, it is imperative to know why it was deleted if indeed it ends up in court. There are two separate entities here at work.
Thank you. And Ms. Putt, did you have any comments regarding the first question about the locus of decision making regarding the request for amendment?
Well I did because it sounded to me that the question was one of decision making as well as the veteran’s rights. It was a two pronged question. It is the author of the document who is supposed to be the one who makes the decision whether or not they believe the information is accurate, timely, relevant, and complete and therefore should remain. If the author of the information is no longer available – they’ve retired, gone to a different VA, etc. – then there is a process in policy to go to the next level through the chain of command, to the chief of the service or the chief of staff depending. But as far as the veteran’s rights, even if an amendment request is denied, they can file a statement of disagreement. They also can request a copy of their original amendment letter to be filed with the disputed information. So they do have some rights that they can exercise that allow them to get their version of the facts, if you will, into the record.
Right and to really simplify it, the patient can request an amendment, if it’s denied they can appeal that decisions, and either way they’re allowed to request for a statement of their own to be put in accompanying it in the record. Is that a safe summary?
Yes, but it’s not just a statement. It’s actually two specific things. They can either have a statement of disagreement which is a very specific document or they ask for their original amendment letter to be put in the record. So maybe I don’t want to write a new statement of disagreement. I don’t feel that I should have to take that time or effort. I can just request that my letter that I sent you be attached and placed in the record.
That’s very helpful. So either way, the patient has the ability to try to have their side of the story included in the record.
Dr. Rasmussen, Portland VAMC:
It sounds like there’s the option for the patient to put an addendum in their record via the statement of disagreement or by approval from the privacy officer. And it sounds like there is the option of actually deleting a note by an administrative deletion. Now in your case where the patient had a dispute with the results of his urine drug screen, does the patient also have the option of actually deleting those lab results from their record.
Yes, I believe that would be possible. If any of our experts disagree, please let me know, but I believe that the information can be removed if the appeal for amendment is upheld.
Beth, Health Information Management Program Office:
I hear the words deletion being used several times. We need to clear that up. You don’t delete things from the record, you retract them. And as the caller from Buffalo stated, the information that is being retracted is discoverable in court. So it’s not actually being deleted and it’s not gone. It’s still in the background and the privacy officer still has access to that document as far as the TIU world is concerned. Some of the ancillary packages – lab and radiology – we have a manual process. A lot of facilities do have a local process on how that’s handled – when you do need corrections made. Another area is comments in the consults package where it doesn’t necessarily follow the same path as an amendment within the TIU package goes. So you should have a local process defined at your facility and your health information manager should be a good resource and person involved in developing that if you don’t already have that.
But by retracting the information, it makes it generally inaccessible. Is that correct?
That is correct. The only person who access to it is by business rules in TIU and it should be your privacy officer or designee.
I was looking for some clarification on that because what I was suggesting was preventive in the event that a veteran would see their note. If a note is entered in error and I catch this before a veteran finds out that there is some misinformation about him in his progress note then I understand now that I should add an amendment to why I am retracting. However, it does call for the word delete. Delete and retracted are both used in the process. My question was is it an administrative function or a privacy act function. I understand now that that would be an administrative function if I’m doing this prior to the veteran requesting it being removed. After the fact if the veteran was aware that there was misinformation in his or her chart, then it would be a privacy act function. Is that correct?
Yes that’s correct. You’re doing an administrative amendment because you have identified the error. It wasn’t at the request of the patient. And this information is all documented and citable in Handbook 1907.1. It’s easy to word search if you pull it up in Adobe Acrobat and do a word search for it. A lot of these particular questions that you have are fairly easy to find in the documentation, specifically how each of these instances should be handled.
And I would think that if you have specific questions about the processes, I don’t want to get to far away from the ethics on this call, but you can take them up with your local HIMS resources or their regional or national counterparts.
Are there any questions about any of the ethical responsibilities that we’ve identified for people when they are documenting things in the health record?
Dr. Singh, Hampton VAMC:
I’m on the Ethics Committee and on the Violence Committee at the hospital here. Recently we’ve started doing patient flagging where if the patient has been violent, there is a flag put on the patient’s chart. I’ve had a few patients who want that removed. Have you run into anything about the ethical problems with that?
Can you tell me a little more about the flags? Are these Type 1 record flags, national flags, or Type 2?
I don’t know what Type 1 or 2 is but these are the local flags that a patient evaluated by the Violence Committee, if they have problems with disruption on the unit or if they are violent, then a flag comes up when you open the patient’s chart in CPRS that says that the patient is a potential violence risk. Depending on the degree, you can call security when the patient comes to the hospital.
Well without commenting on the specifics on a particular case, since we certainly don’t want to do that here and we don’t know the circumstances, again I think that the underlying principles are that the patient has a right to question whether something in their record really should be there and the criteria of accuracy, timeliness, relevance and completeness are those criteria that the information needs to be assessed again. And if the people who are responsible for putting it there, if the institution feels that the information meets that criteria then I think that the point is that the patient is told and that the information stays and then the patient gets to be able to put their statement in.
Barbara, Health Information Office:
That’s right. And before those Type 1 category flags are placed on behavior, they go through a vetting so they are not done in isolation. But again as you said, the patient would certainly have the right to request a change or amendment to that flag but it would have to go through the process.
Again, the process being the same through the patient advocate and the committee?
It would be the process that is described in the policies and that Barbara described – a written request stating why the specific information is not felt to be accurate, timely, relevant, or needed for completeness.
On the actual letter where we say we can file it in the record for them if we don’t agree to change it, are you scanning those in as an attached addendum to whatever they are asking to be amended with a special title or how are you handling that now that it is electronic.
Well again, from an ethics standpoint, I really can’t answer that. And I’m not sure how prescribed that is in policy or how much that is up to local policy. Would our colleagues from our other offices would like to answer this but the point is there’s a mechanism that it gets in. And I think if you have specific questions locally, again I would refer you to your local privacy officer or your local health information management resources who can get you those specific process answers through their own resources if they don’t know them.
Susan Helbig, Seattle VAMC:
Is there an ethical consideration of where the letter from the patient would be placed? If the patient really wants it so that all care providers actually see that he or she has disagreed with the decision not to amend the portion of the record.
As I understand it, and please correct me if I’m wrong, it ends up being placed adjacent to or with the information that is not amended. So in theory I believe it’s met so that when you see the information the patient feels is in question, you will also see there response or side of the story.
Jeff Corzatt, Office of General Counsel:
There’s guidance in VHA Handbook 1605.1 and VHA Handbook 1907.1 for the record and how to amend the record under the Privacy Act.
I’m wondering since this is an ongoing concern in VA facilities and there seems to be some recognized problems in the way that documentation is entered into the medical records, I’m wondering if any facilities out there have tried to take a systematic look at trying to reduce the number of amendments that are requested by improving the document in the medical record. Is there anyone out there working on such a project?
Has anyone taken a look at the tangential topic that we’ve talked about – maintaining professional tone in the record? Does anyone have any training that they use or systematic way to communicate standards to their providers?
Laurie Bartell, Sheridan VAMC:
We developed a clinical informatics medical records committee that developed a 52 page PowerPoint that covers all the issues with documentation and that’s a mandatory training for all of our staff who have access to CPRS.
Would you be willing to share that with the Ethics Center so that we can take a look at it?
Certainly. When we had our SOARS inspection, they were extremely impressed with that and asked for a copy of it.
Julia, Hampton VAMC:
Would it be possible for us to get a copy of that also?
I think so. We just need to take a look at it first. But in theory, I think that that is something that we probably could put you in touch with our resources in Wyoming. Perhaps we may be able to send a reference to it in the follow-up email that we send with the call.
Jill, El Paso, TX:
That would be great. We would appreciate a copy of that.
Just remember that the Ethics Center does do that, it is not necessarily our endorsement of the PowerPoint or of the content. It would be a pass along.
We have received reports of a certain type of problem that sometimes shows up and that is when there is a dispute between the clinician and the patient that would result sometimes, in this highly subjective, pejorative, irrelevant documentation. And I wonder if you have had reports of those kinds of things at the local level where patients have requested or you’ve observed it yourself as a clinician in looking at the records.
The reason we developed this mandatory training was because of issues that we did identify. We are the tertiary psychiatric facility for VISN 19 and we were seeing some significant issues we felt as a committee and wanted to do some retraining of staff.
Have you been able to assess the effectiveness of the training? Have you looked back at records prior to offering the training and then afterwards or evaluated in some way whether the training was effective:
We have and also at the request of our committee, I’ve met personally with each one of our units and gone through the slides and training and answered questions.
That’s very helpful. Thank you.
FROM THE FIELD
David, Salem VAMC:
I guess this may be a comment and it’s directed back towards the Privacy Office and the HIMS Office. With regard to statements earlier about what we can correct or I should say amend in the record. Currently the functionality in CPRS seems to be limited as far as what we can actually make corrections to. Basically progress notes, discharge summaries, operative reports – things of that nature. There is an example given of problems with consults or maybe where a lab test was inappropriately place somewhere – those various ancillary packages. The comment was to go and look at your local methods for doing it. I would like to recommend that we have a standardized protocol set up and published that everybody follows so that we’re all doing it the same way.
Thank you for that comment. I didn’t mean to say that your local resources should be developing those protocols. I just meant to say that if you have questions about how it should be done, your local HIMS and Privacy Office staff would be the ones who would work with their national resources to first put in place what’s required and then to work with other resources to promote change if it’s really needed. I wouldn’t want the take home message from me to be that everyone should be doing it at their local level. It really is something that should be done as I just described so thank you.
One other thing that I would like to discuss down the road are psychotherapy notes as they relate to what I was used to in the private sector of that being a separate file and how people are using the actual medical record electronically for psychotherapy notes.
I have strong personal feelings about that. Over the years we’ve had different groups come forward and say that they feel that a particular subset of information should be kept segregated from other information. I think in general on analysis, that that is probably not a good idea in the sense that segregating the information defeats a lot of the purposes of a complete and accurate, timely and relevant record. Again, it really is the responsibility of all of our people who have access to the record to access that information on a need to know basis and to respect the privacy and trust that comes with accessing that information. So I’m personally not of the sentiment that segregating information is good for the patient or good for the system. I think that it is recognition of the purpose of the chart and responsibilities of people accessing it, that’s where our efforts need to be made. I don’t know if you disagree with that but that’s how I think about it.
No I asked that question because it was addressed when we initially went through HIPAA training some years ago that the handwritten notes done by the psychotherapist, that they would still document in the medical record but not all the significant details.
I had wanted to point out that by your comment that psychotherapy notes by definition are not part of the VA medical record. Any information documented in the VA medical record would not be considered a psychotherapy note it would be considered a mental health clinical note or a progress note. But by definition, psychotherapy notes are the personal session notes of the psychotherapist, psychiatrist or counselor. They are not part of the VA record and never should be. They are used as you said to create the official documentation for the VA record and that is all address in VHA Handbook 1605.1.
So are those notes from the practitioners to themselves?
Yes. There are considered to be the practitioner’s notes during a therapy session where they may write a lot of details – a play by play of what was said during the session. Where there are not going to put all that detail or they don’t need to put all that detail into the official record. They would summarize how the therapy session was going, how progress was going but they would not have all of the play by play of what was stated.
And I assume that that determination is made on the same standard that we’ve talking about that those details are not necessary to have a relevant, complete, accurate and timely record.
Well, as usual, we did not expect to conclude this discussion in the time allotted, and unfortunately we are out of time for today's discussion. We will post on our Web site a very detailed summary of each National Ethics Teleconference. So please visit our Web site to review today's discussion. We will be sending a follow up email for this call that will include the links to the appropriate web addresses for the call summary, the CME credits, and the references referred to.
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Roach, WH. Medical Records and the Law, 3rd edition. Gaithersburg, MD: Aspen Publishers, 1998.
Privacy Act, 5 USC 552a.
Harman, LB. Ethical Challenges in the Management of Health Information, Gaithersburg, MD: Aspen Publishers, 2001.
VHA Handbook 1907.1, Health Information Management and Health Records.
VHA Handbook 1605.2, Minimum Necessary Standards for Protected Health Information.
VHA Handbook 1605.1, Privacy and Release of Information.
VHA Handbook 1004.1, VHA Informed Consent for Clinical Treatments and Procedures.
VHA Handbook 1106.1, Pathology and Laboratory Medicine Service Procedures.
Jenkins G, Merz JF, Sandar P. A qualitative study of women’s views on medical confidentiality. Journal of Medical Ethics 2005; 31(9):499-504.
Klitzman R. The quest for privacy can make us thieves. New York Times May 9, 2006.
ed when we initially went through HIPAA training some years ago that the handwritten notes done by the psychotherapist, that they would still document in the medical record but not all the significant details.
Yes. There are considered to be the practitioner’s notes during a therapy session where they may write a lot of details – a play by play of what was said during the session. Where there are not going to put all that detail or they don’t need to put a