By Ken Pope
Canadian Psychology
Vol. 56(3), August 2015, 348-356
Abstract
The growing array of record-keeping laws, ethical standards, and professional guidelines has created controversy and confusion. Clinicians struggle with what to leave in, what to leave out, how to handle records securely, when to respond to requests for records versus when to refuse, and so on. This article focuses on 5 challenging areas: confidentiality; informed consent; the state, the law, and legal requirements; third-parties; and the implications of research findings for record keeping. It discusses published claims, critiques, proposals for change, and research reports, particularly those of Bemister and Dobson (2011, 2012); Castonguay (2013); Christie, Bemister, and Dobson (2014); Furlong (2013); and Mills (2012). It emphasizes the potential problems with any “1 size fits all” approach and the difficulties in creating sensible regulations that do justice to the diversity of values, contexts, cultures, and theoretical orientations.
The entire article is here.
Showing posts with label Record Keeping. Show all posts
Showing posts with label Record Keeping. Show all posts
Monday, September 14, 2015
Monday, October 15, 2012
Letting Patients Read the Doctor’s Notes
By PAULINE W. CHEN, M.D.
The New York Times
Originally published on October 4, 2012
Here are some excerpts:
This patient’s experience, like those of so many others who have tried to obtain their medical records, came to mind this week when I read about the long-awaited results of a study in which patients were given complete access to their doctors’ notes. The findings, published in the Annals of Internal Medicine, do more than shed light on what patients want. They make our current ideas about transparency in the patient-doctor relationship a quaint artifact of the past.
Since 1996, when Congress passed the Health Insurance Portability and Accountability Act, or HIPAA, patients have had the right to read and even amend their own records.
In fact, few patients have ever consulted their own records. Most do not fully grasp the extent of their legal rights; and the few who have attempted to exercise them have often found themselves mired in a parallel universe filled with administrative regulations, small-print permission forms, added costs and repeated delays.
(cut)
For one year, the study, aptly called OpenNotes, allowed over 13,000 patients from three medical centers — the Beth Israel Deaconess Medical Center in Boston, the Geisinger Health System in Danville, Pa., and the Harborview Medical Center in Seattle — to have complete access to one part of their medical records, the notes that doctors wrote about them. Within days of seeing their doctors, patients received an e-mail inviting them to read the doctor’s signed note on a secure patient Web site. Two weeks before their return visit, patients received a second e-mail inviting them again to review their doctor’s note from the previous encounter.
After a year, almost all the patients were enthusiastic about the OpenNotes initiative.
Surprisingly, so were the majority of doctors.
The entire article is here.
The research from the Annals of Internal Medicine is here.
The New York Times
Originally published on October 4, 2012
Here are some excerpts:
This patient’s experience, like those of so many others who have tried to obtain their medical records, came to mind this week when I read about the long-awaited results of a study in which patients were given complete access to their doctors’ notes. The findings, published in the Annals of Internal Medicine, do more than shed light on what patients want. They make our current ideas about transparency in the patient-doctor relationship a quaint artifact of the past.
Since 1996, when Congress passed the Health Insurance Portability and Accountability Act, or HIPAA, patients have had the right to read and even amend their own records.
In fact, few patients have ever consulted their own records. Most do not fully grasp the extent of their legal rights; and the few who have attempted to exercise them have often found themselves mired in a parallel universe filled with administrative regulations, small-print permission forms, added costs and repeated delays.
(cut)
For one year, the study, aptly called OpenNotes, allowed over 13,000 patients from three medical centers — the Beth Israel Deaconess Medical Center in Boston, the Geisinger Health System in Danville, Pa., and the Harborview Medical Center in Seattle — to have complete access to one part of their medical records, the notes that doctors wrote about them. Within days of seeing their doctors, patients received an e-mail inviting them to read the doctor’s signed note on a secure patient Web site. Two weeks before their return visit, patients received a second e-mail inviting them again to review their doctor’s note from the previous encounter.
After a year, almost all the patients were enthusiastic about the OpenNotes initiative.
Surprisingly, so were the majority of doctors.
The entire article is here.
The research from the Annals of Internal Medicine is here.
Friday, July 13, 2012
California places psychologist David Van Zak's license on probation
Psychiatric Crimes Database
Originally published July 5, 2012
On January 26, 2012, the California Board of Psychology placed DAVID VAN ZAK, Ph.D.’s license on probation for five years. According to the Board’s Accusation, Van Zak committed, among other things, repeated acts of negligence by accepting financial gifts from a patient, as well as the patient’s invitation to join her and her husband on a Mexican cruise.
The entire story is here.
Originally published July 5, 2012
On January 26, 2012, the California Board of Psychology placed DAVID VAN ZAK, Ph.D.’s license on probation for five years. According to the Board’s Accusation, Van Zak committed, among other things, repeated acts of negligence by accepting financial gifts from a patient, as well as the patient’s invitation to join her and her husband on a Mexican cruise.
The entire story is here.
Thursday, November 24, 2011
Thursday, August 11, 2011
Canadian Psychology: Ethical and Legal Considerations of record keeping
An updated account of the ethical and legal considerations of record keeping.
Bemister, Taryn B.; Dobson, Keith S.
Canadian Psychology/Psychologie canadienne, Jul 25, 2011
Abstract:
The Canadian literature is void of contemporary guidelines for clinical record keeping for psychologists, as the most recent article was published more than two decades ago (Eberlein, 1990). However, the techniques used in record keeping have greatly advanced, specifically with regard to the role of computers and the use of electronic documents. Furthermore, new legislation and guidelines have been developed in response to these technological advancements. The purpose of this article is to provide a concise, accessible, and up-to-date set of guidelines on record keeping in psychology. The professional and legal requirements of psychologists are discussed with regard to the use, content, access, ownership, and retention of records with special consideration given to electronic documents. Recommendations are made for Canadian psychologists that are consistent with the current legal and professional standards of the field. Beginning of the article:
The Canadian literature is void of contemporary guidelines for clinical record keeping.
Although books that contain information regarding record keeping have been published more recently (e.g., Evans, 2004 and Truscott & Crook, 2004), the most recent article dates back to 1990 (Eberlein, 1990).
Eberlein's article was written largely in response to the establishment of the Canadian Code of Ethics for Psychologists (Canadian Psychological Association [CPA], 1988; herein referred to as the Code of Ethics).
However, two revisions of the Code of Ethics have been published (1999 and 2001), and the techniques used in record keeping have advanced, specifically with regard to the role of computers and the use of electronic documents.
Beyond the above developments, the federal Personal Information Protection and Electronic Documents Act (PIPEDA) was introduced in 2000, and it has modified the statutes relevant to records.
Similarly, a draft of guidelines for psychologists who provide psychological services via electronic media was developed (CPA, 2006; to be finalized).
A second exerpt:
The purpose of this article is to provide a concise and accessible resource on record keeping that is up-to-date with the advances that have occurred since 1990.
This article provides a comprehensive overview of the issues related to record keeping and provides recommendations for Canadian psychologists.
More specifically, the professional and legal requirements of psychologists are discussed with regard to the use, content, access, ownership, and retention of records with special consideration given to electronic documents.
The implications of technological advances on client confidentiality and privacy are also considered.
The suggestions made in this paper are consistent with the Code of Ethics, as well as legislative and provincial laws and regulations, including the Code of Conduct (or its equivalent) of each province and territory.
The author note provides the following contact information: Taryn B. Bemister, Department of Psychology, University of Calgary, Calgary, AB T2N 1N4, Canada. E-mail: tbbemist@ucalgary.ca.
Thanks to Ken Pope for the information.
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