Patient rights requirements in health information management

Patient rights requirements in health information management

Introduction

Physicians have a professional responsibility and a legal obligation to protect the confidentiality of patient information. Given the legislation on privacy and legal complexities relating to the ownership and management of patient information, many doctors are wondering whether or not they can give patients and third party access to this information. In United States of America, doctors, schools and clinics are owners of files, regardless of format, and they hold information on patients who are documented in these files in trust for the benefit of the patient and for his care. Each patient retains a right of access to personal health information, including information from other sources, such as consultant's reports. In general, patient information must not be disclosed without the written permission of the patient or substitute decision-maker, upon receipt of a court order, or when the application is specifically designed for a purpose authorized by law. A substitute decision-maker is a person legally authorized to make decisions on behalf of the patient when it is mentally incapacitated. This authority may be granted by the patient, through a legal document such as an advance directive or power of attorney covering personal care by a provincial or territorial legislation or by the courts. Patients have a right to access information contained in their medical records. In exceptional cases, doctors may refuse to disclose patient information in the file, but only when he reasonably believes a significant likelihood that the disclosure will have a marked adverse effect on the physical, psychological or affective patient, or it will cause damage to a third party. In such circumstances, it is up to the physician to justify the refusal of access to patient information in the medical record (Oregon, 1999).

Discussion

Patient autonomy is a valuable asset. Under United States law, the patient's right to self-determination is ensured by a corresponding duty of the physician to inform. Owing to various case laws of the courts over the last few decades, that duty, about in all of its aspects (i.e., informing the patient about risks and benefits, about the diagnosis, about the course of treatment, about Necessary patient compliance, and potential treatment costs) has gained enormous attention jurisdictional and scientific as well as forensic importance. Established court practice has become highly elaborated and differentiated. Some precedents have, exceeded reasonable requirements for physicians, and moderation is advisable. The current plans concerning a statute on the Protection of Patients 'Rights in Germany aim at laying down the specific requirements for patients' informed consent, including what information has to be communicated and in what way. Such a goal is difficult, especially in light of regulatory techniques. The discussion about the statute seldom addresses the fact that the suitability of legal norms as a means for public guidance can be limited, in particular, they do not guarantee that a dialogue between patient and physician about risks and benefits will ensue on the basis of a ...