Healthcare providers may legally own medical records, but patients own the information held within the record — posing a challenging ethical landscape for physicians to navigate, according to the most recent edition of the American College of Physicians' ethics manual.
The American College of Physicians published the seventh edition of its ethics manual in the Annals of Internal Medicine Jan. 15. The document covers various issues in medical ethics, including confidentiality, informed consent, gifts from patients, social media use and physician-assisted suicide.
"Reexamining the ethical tenets of medicine and their application in new circumstances is a necessary exercise," the manual reads. "The manual is not a substitute for the experience and integrity of individual physicians, but it may serve as a reminder of the shared duties of the medical profession."
Five notes on EHRs, as outlined in the American College of Physicians' recently updated ethics manual:
1. Physician entries in patient medical records must contain "accurate and complete information about all communications, including those done in-person and by telephone, letter or electronic means."
2. EHRs should facilitate patient care, and therefore should support clinical reasoning. Features such as copy-and-paste should be used carefully, and only if they produce an accurate medical record.
3. Legally, the physician or healthcare institution owns the medical record. However, the information within the record is the property of the patient.
4. Ethically and legally, patients have the right to know what data is documented in their medical record. The physician must release this information to the patient or to a third-party if the patient requests it.
5. If a physician leaves a group practice or dies, their patients' medical records should be forwarded according to the patients' instructions. Physicians must be aware of relevant state laws related to the retention of medical records.
To access the newest American College of Physicians' ethics manual, click here.