One day this spring, an elderly patient of mine became upset with me because, she said, I had betrayed her trust.
The issue was a short note I had written in her medical record about her difficult relationship with her child. The note was a reminder for me and anybody else in the hospital where I worked that the patient didn’t have anyone who could accompany her to appointments.
A specialist my patient was also seeing was using an electronic record system that automatically put my note into his. When he shared his notes with her, my patient became angry when she saw what I had written. I thought that information was between us, she said. The note seemed disloyal to her, so at her request, I deleted it.
The exchange left me feeling uneasy. The information might be important if she were hospitalized or in an accident, but she also has the right to decide what she wants her doctors to know.
As more and more doctors’ offices give patients electronic access to their medical records, both patients and their physicians are asking: Exactly how much of your medical record should you get to see?