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Ethical Issues in Disclosing to Patients: Should Patients Be Allowed to Read Their Charts?

Ethical Issues in Disclosing to Patients: Should Patients Be Allowed to Read Their Charts?

Suggested strategy when a patient asks to see his or her medical chartTable: Suggested strategy when a patient asks to see his or her medica...

Should patients be allowed to read their charts? A patient may reason, “It is my medical record, I paid for it, and I have the right to see it,” or the more vexing, “My insurance company read my chart, so I should have the right to read it!” Yes, the patient likely signed a form acknowledging that insurance companies have special access under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), but at that time the patient had little awareness of a future desire to see his or her own chart.

A psychiatrist may feel it is counter-therapeutic to disclose the raw material in the chart. Perhaps it will inspire shame, hopelessness, or anger. A psychiatrist may be insecure about revealing poor record-keeping habits or, more subtly, may feel discomfort with the notion that reading the chart allows the patient to glimpse into the psychiatrist’s mind.

There has been substantial controversy about whether patients should be allowed to read their psychiatric record. Traditionally, patients have not had the legal right, but this has changed in recent decades, and federal law now strongly supports a patient’s right to view the chart on request. Here I review the ethical and legal factors involved in this challenging situation.

Double jeopardy

Ethical arguments about a patient’s right to see the psychiatric chart balance autonomy (the patient’s decision whether to view the chart) and respect for persons (the patient’s right to have maximal autonomy) against the principles of non-maleficence and beneficence (both as judged by the clinician). Also relevant is the duty of veracity/truth-telling that may be compromised not only by lying but also by omission (eg, not disclosing the chart).

Does releasing the chart to a patient risk causing harm to the patient or someone else? If so, what level of risk may be acceptable? Could reading the chart be helpful to the patient? These are difficult questions to answer when a carefully created therapeutic alliance hangs in the balance between psychiatrist and patient. This alliance is the soil for productive psychological work, and psychiatrists are loath to imperil it by turning over a copy of the psychiatric record.

It should be recognized, however, that a patient’s request to read the chart is a point of double jeopardy for the treatment relationship, which is endangered whether access is granted or denied. At this point, we must remind ourselves that it is the patient, and not the therapeutic alliance, that is to be prioritized. The long-term benefits of strengthening patient autonomy should not be hindered without good reason.

How do we predict the risks and benefits of granting or denying access to the chart? Several related studies offer guidance.1,2 Examination of the content of psychiatric case notes revealed that up to 80% contained elements that were potentially puzzling, offensive, alarming, or upsetting to patients.3-5 Studies of the impact of patients’ review of their charts have been conducted primarily in acute inpatient settings, usually during active treatment and with direct supervision. A substantial percentage (35% to 50%) of inpatients felt more pessimistic or upset after reading their records, but there was also a consensus that little or no substantial harm was involved.6-8

Most inpatients who read their records reported that they felt better-informed and more involved in treatment.6 Some patients with psychotic diagnoses thought it demystified the medical record.9 Staff members reported that the studies changed their charting practice (eg, by minimizing upsetting notations and psychotic diagnoses), and they observed that important communications sometimes failed to be charted.6,10

Outpatient data are scarce; however, one study reported benign results when carefully screened outpatients read their records in a clinically supportive setting.11 These studies do not take into account the subpopulations of patients who spontaneously make requests to see their chart, although one retrospective study suggests a preponderance of character disorders and contentious treatment relationships.12 The available literature is limited in broad applicability, but it suggests that while clinicians fear the risks of chart disclosure, the practice in supervised settings has been benign or even beneficial.

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