I have a patient who is married, and they are cheating on their spouse with a person who also has other partners. They came in to my Internal Medicine practice for STD testing. I counseled them to seek marriage counseling; I counseled them on their risky behavior; I ordered the requisite testing.
This has been a common scenario with both my male and female patients, and though I am always sad and concerned for the patient, their unsuspecting partner, and their children, I know that legally I cannot do anything about this, apart from offer my best nonjudgmental counseling, and treat the patient as is medically appropriate.
But then, this patient asked me to edit the chart. They demanded that I go back into my note in the Electronic Medical Record (EMR) and erase all mention of any affair. The reasoning: If they end up in divorce court, these records can be subpoenaed, and my notes, which document the affair as the risk behavior requiring STD testing, would then be revealed. This patient could then lose out big on custody, alimony.
With our EMR, we can do this. We can simply open the note, check off "Amend note", check off the reason on a drop-down list ("Patient Request" is an option, also "Erroneous information"); change the note; then re-save. The note is then labeled as "Amended", and I'm sure the original information is recorded somewhere, though only accessible to our IT personnel.
But I did not do that. I explained to the patient that her extramarital affair with a high-risk individual needs to be included in the note, as it is medically relevant. It justifies our STD testing, and alerts other providers to possible STDs. The patient was livid.
I did not change the record. But the request bothered me so much, that I put it out to colleagues, asking them what they have done in similar circumstances. The topic raised much interest, as many of us have been asked to edit the medical chart, or omit things from it entirely, for various reasons.
Most commonly, at our practice, we are asked to edit or omit information by patients who are also employees of the hospital where we work, and who have access to their charts (via the EMR). For example, a patient asked me to go back and edit my documented physical exam, where I wrote “The tonsils were not enlarged”, because she had a tonsillectomy as a child. She had read my note, and was appalled that I had written about her tonsils. I had a patient who wanted “Diabetes” taken off of her problem list because they planned to lose weight and reverse the diagnosis: “It’s not a real diagnosis yet, and it’s embarrassing” she explained. Others have wanted psychiatric diagnoses excluded from the problem list, afraid that another colleague may see their chart, or afraid that the diagnosis would ruin their chance to get any good disability insurance.
I consulted with Risk Management about my patient’s request to go back and delete any mention of an affair; Risk Management advised me that if the editing is to correct a factual error, then the chart can and should be edited. But for any other reasons, such as patient request, the chart is considered a medicolegal document, and while it can be altered, they advise against that. What the doctor chooses to include in the chart in the first place is up to them, but should be medically accurate.
I was very satisfied with this answer: It matches my own sentiments pretty well. If the chart is just plain wrong, it needs to be corrected. But if the information is accurate and medically relevant, then no, it cannot be edited, NOR omitted. I assumed that my colleagues would feel the same way.
I was wrong. At a recent luncheon, I asked some colleagues what they thought about this, and in a room of about 8 providers, only one leaned towards my view. All the others regularly omit sensitive information- including any mention of affairs, for example- and though many admitted discomfort around this issue, most will edit the chart upon request. One doc has just stopped putting “Obesity” in the list at all, for anyone. “People feel judged by that label, insulted, even,” she explained. “I know they’re obese. Anyone who looks at them will know.” Another doc omitted that a patient claimed to be a hit-man, as she was worried for her safety should the charts get subpoenaed. (I could actually see her point there). Many do not list psychiatric diagnoses in the problem list, and it was split on some illicit behaviors, such as at-risk drinking and recreational drug use. In general, most docs felt that insisting on including “sensitive” information was bad practice, as it could mean losing your patient- they just won’t tell you anything anymore.
One senior doc told me “Sensitive information can really hurt them if it ends up in court, and you’re naïve if you think it doesn’t”.
Well, actually, I fully realize that the information about a documented affair, or a drug habit, or gambling problem, etc. could hurt the patient’s chances in divorce court, and adversely affect their alimony and custody settlement. But I’ll be damned if I will lie on behalf of a person who is engaging in risky and dangerous behaviors. To me, that is collusion. My hands are already tied, as a physician, as I cannot warn the spouse that they are at risk for STDs, or that their finances are being drained as the patient spends it all on drugs or gambling. It’s upsetting enough that I am silenced in this way, and cannot take action beyond offering guidance and resources to the patient. Do I also need pressure to collude with the patient, to keep them clean in the court of law?
Basically, at this luncheon, most of the docs felt that barring things like IV drug use and cocaine abuse, which are pretty essential things for another provider to know about, the patient should have some say over what is included in the chart. The reasoning was that this fosters the doctor- patient relationship, by ensuring supreme confidentiality, and thus inspiring trust. All agreed that they would never have mentioned my patient’s affair in the chart; they would have simply documented their complaints, exam, and the testing, with no mention of risk factors.
So I asked this of the group: If you leave things out of the record, what happens when your patient shows up in the emergency room unconscious and you haven’t documented their depression, or at-risk drinking, or marijuana habit in the problem list? Or when they see another provider for pelvic pain and you haven’t documented their risky sexual behaviors? What about when you spend 15 minutes counseling the patient on their gang activity, or gambling, or binge eating-- how do you NOT document that for billing, NOT document that for the next provider?
Where do you draw the line on what you do and don’t include in the chart?
At this meeting, there was no consensus here, just: “It depends what the issue is, whether it needs to be in there or not.” Most material seems to be in a sort of ethical gray zone: “In general, it’s not worth risking the relationship with the patient,” one colleague stated.
I was frankly depressed that day. I’m no Mother Theresa, but I did feel disappointed in my colleagues. If anyone can make their doctor edit the chart to suit their needs, then what good is the chart as a document of their medical history?
I am curious to hear what others feel on this issue, and how they practice. Are these colleagues typical, and am I an anomaly?