Sunday, March 2, 2014

Release of medical record

We are sometimes asked by a patient to release the medical record.

I write medical record whenever I meet a client in a hospital. Recording is a duty as a doctor. The medical record is an evidence of treatment. It describes what I plan and perform for the patient.

Then, who is the owner of the medical record?

It is a question which was suggested decades ago. Traditionally, the medical record was deemed as a memorandum of a physician. Many doctors wrote a medical record only for themselves. Thus, it frequently occurred that no one other than the writer can read the record afterwards.

Late 20th century, team operation had been developed in medical situations. The roles of comedical staffs were emphasized. Then, the medical record was also shared within the team.

In Japan, the common language of the medical record was German before. It changed to English, and then into Japanese. Young doctors seldom write German terms, except "Karte," means medical record.

Nowadays, almost all medical records are written in Japanese. In many cases, they are digitized. This enables us to read the record with ease. Nevertheless, there are few patients who want to see their own medical record.

As a principle, the patient has right to investigate it, because it includes some critical information about him or her. However, in some occasions the wish by a patient to watch the medical record is rejected. For example, the record can include some information which may affect the patient's status adversely.

From my experience, most patients who read their medical record tended to lose their control of emotion. The main reason is that, at least in Japan, patients who have a need to disclose their medical record is involved in some troubles around their own treatment or another. Patients who are doubtful to the content of treatment dare to watch the medical record. Unfortunately, it may make them more anxious.

Therefore, though release of medical record is a modern principle, it would not relieve the patients.

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