Patients reading their own charts-yay or nay?

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Sorry, had to remove original post.

I think someone knew who I was talking about, and thats not kosher, since I was trying to be vague enough not to violate any privacy rules

Specializes in CCU-Med Surg.

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.

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Ok, from the ANA website at http://www.nursingworld.org/readroom/position/joint/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.

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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.

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Specializes in ICU, ER, Hemodialysis.

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!!!!!!!

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Specializes in Education, Acute, Med/Surg, Tele, etc.

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!

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Specializes in Acute Care Psych, DNP Student.
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.

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Specializes in NICU/Neonatal transport.

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."

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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.

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i am fresh out of hospital orientation and the law is that the patient can read or have copies of their charts but you have to call medical records, they come and bring a release for the patient to sign. yes the argument is that it is thier body but the records belong to the hospital. so just follow the steps of the law for your place of employment. fluffy :blushkiss :blushkiss :blushkiss :blushkiss :blushkiss

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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.

As a fellow nurse: I agree with you whole heartedly. In this particular case- the discharge planning from SS was nonexistant. My mom was terrified and completely freaking out as he was put on the rehab floor and she recieved a MESSEGE that he was to be discharge the day after discharge from ICU. Noone took the time to explain anything to her- and she naturally assumed the worst. Per hospital policy- I was not permitted to transfer or ambulate my dad as it was after PT hours. The nurse in this case was very understanding and more than willing to help another nurse clear up the situation with a few simple answers. At that time- I'm sure I was much easier to deal with than my terrified mother!

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I think the patients have every right to read there charts. I would read my chart i would want to know what was wornge with me. So i think it should be up to the pacient if they want to read there own charts or not. I could understand if anyone else but you the pacient wanted to read your chart with out your premission.

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Specializes in LDRP.
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

what types of errors?

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