[mellomom]

I've read my own chart too... while in the room, waiting for the ARNP who was called out for an emergency. While she was "suprised" I didn't feel she was angry. I discovered she had a horrible transcriptionist!

Once I read my son's chart and found a significant transcription error related to a steroid dosage...they would have been toast if he had had an adverse outcome because it looked like he'd been prescribed a 10-fold increase over normal....

I think since it's your info, you should be able to see it. I take the patient's chart in their room with me if they request it so they can see labs, etc. It really defuses upset/concerned POA/s and patients...

[TazziRN]

No, unless the PHYSICIAN is there while they read it. If the pt or relative is an RN or MD or anything in between, I would have no problem allowing it, but for the general public, I think the MD should be present to interpret.

[maddynrs]

I know as a nurse I would actually like to see my chart and what the doc's write about me concerning my progress. I agree that the pt should have a right to review the medical documents, but there must be a way of doing it that will not compromise the integrity or safety of the site at hand. i.e. the primary nurse should not be expected to "drop everything" and sit in the room while the pt reads the chart like the sunday paper. The nurse has WAY more important things to accomplish in her/his day. I know I sure do. I believe, at my facility, the process is that you have to go through medical records and if you want the info there and now, you have to have an MD available to speak with you about the issues at hand. I think it's more of a safety net for the hospital, but still, I think it's a viable option.
Just my opinion.
P.S. by the way, I'm a newbie. Can you tell?
m.

[KeithEMU]

Ok, from the ANA website at http://www.nursingworld.org/readroom...int/jtdata.htm:

Access by the Patient: Individually identifiable patient health care information is private and is often sensitive. Therefore, the need to limit disclosure of such information is universally recognized, as is the concept that under most circumstances, only the patient has the right to authorize the release of the information to third parties. However, no such consensus exists on the right of a patient to see his/her own health record. In 1994, 27 states have laws specifically regulating patient access to his/her health record. Some of these laws expressly prohibit a patient from reviewing his/her health record without authorization from the practitioner/health care provider. States with no patient access legislation leave the decision to health care providers. Federal laws granting a right to access exist, but only for specific patient populations. Health care professionals generally acknowledge that the information in the record is the property of the patient. Yet, in many states, access to the information may be denied to the patient. However, there is growing recognition of the fact that the patient's access to his or her records can help the patient become more involved in his or her health care. This can actually improve both the quality of care and outcome of care.

[NrsJena]

Originally Posted by multicollinarity

I believe it is patient's fundamental right to read his/her chart. That includes allowing a representative to read the chart.

This is actually open to all sorts of interpretation. When my dad was in the hospital for a stroke, the day before discharge- I asked to see his PT eval (needed to know his balance, transfers, distance, etc.)-the nurse verified his approval, but told me it was hospital policy to have the DR. present. The DR was not in the hospital and the attending was "unavailable". We side stepped this by me reading over the nurses shoulder. (she was awesome and very understanding...

edited for spelling.

[jb2u]

i say NAY!

yes they have a right to the info in the chart, but the chart belongs to the hospital or office not the patient. if they want this info there is a reason that they must go through the "proper channels" to get a copy of it.

first of all there are things people just do not understand. what if they read some long medical term that looks horrible and freak out because they think they are about to die. what if they read SOB on their chart and get irate because they are unaware that it stands for short of breath. seems far fetched to us, but maybe not to someone outside of the healthcare setting.

secondly, what if a test came back positive, but the doctor has not arrived at the hospital to tell the patient. if a pt has cancer can the nurse go in and tell the pt "the biopsy results came back and you have cancer?" no! so why should the pt be free to just read the chart?

i understand the emotional need the pt has for wanting to read the chart. i would probably want to read it myself. however, that does not mean it is the right thing to do. as the saying goes there is a time and place for everything.

and that's my 1 cent....i get the other cent after completing my second year of nursing school.............jay's two cents coming to you in May 2007!!!!!!!

[TriageRN_34]

MD must be present for a patient to read their chart...or the MPOA. I like that, takes that valuable time off me and puts the power to change things or discuss things in the hands of the person that will be the one signing changes in the first place!

[multicollinearity]

Originally Posted by NrsJena

This is actually open to all sorts of interpretation. When my dad was in the hospital for a stroke, the day before discharge- I asked to see his PT eval (needed to know his balance, transfers, distance, etc.)-the nurse verified his approval, but told me it was hospital policy to have the DR. present. The DR was not in the hospital and the attending was "unavailable". We side stepped this by me reading over the nurses shoulder. (she was awesome and very understanding...

edited for spelling.

I believe it is the patient's fundamental right to read his/her chart or a designated rep. That said, I do not believe they are entitled to medical interpretation at their leisure while they read the chart. I don't think the doctor should be required to be there while they read the chart - come on, they are as busy as we are. I think the patient or rep should be able to read the chart with a clerk present from medical records. If they wish to have the chart explained, then they can make an appointment with the doctor. In short, they have a fundamental right to read their records but that doesn't mean they have a fundamental right to instant interpretation on demand from busy professionals.

[LilPeanut]

I think it is a right to access your own chart.

I learned to read the charting when my son was in the NICU. I would come in in the morning, the nurses would give me an update overnight, then I would read the chart to get the specifics of what happened, how long he was awake, if he was crying a lot, etc. I wasn't able to be with him there 24/7, and reading the charting helped me to feel like I knew what happened when I wasn't there, outside of just "oh, he was fine."

[BMW10]

I agree, the patient SHOULD have access to their chart. But I know that many frown on such a practice. I'd like to take the proposition one step farther: Should the patient be allowed to enter THEIR OWN comments?

Case in point: My Mom was readmitted for a nasty post-op infection and dehissance of her joint incision three days after removal of her skin staples. Needless to say, the repair broke down and she required even more major surgery after the infection cleared. We asked for, and received from Medical Records (weeks post-discharge), copies of her OP notes and progress reports so we'd have them available for the consulting specialist. We were surprised to discover how many errors had been entered into the record...and how impossible it would have been to make appropriate corrections weeks later.