Privacy, Confidentiality &Amp; Medical Records
Content
Saudi Commission for Health Specialties
Professionalism and Ethics Education for Residents (PEER)
Privacy, Confidentiality and Medical Records Dr. Ghaiath M. A. Hussein
Asst. Prof., Dept. of Medical Ethics King Fahad Medical City – Faculty of Medicine King Saud Bin Abdul-Aziz University for Health
Outline Definitions and differences How to maintain the privacy of our patients? How to maintain the confidentiality of our patients’ information? When to disclose medical information
Privacy and ? Confidenciality
Confidentiality : Privacy:
- Is the right of an individual to have personal, identifiable medical information kept out of reach of others.
- A right or expectation to not be interfered with - Be free from surveillance - A moral right to be left RESPECTS PATIENT’S RESPECTS PATIENT’S alone. INFORMATION
BODY
PRIVACY
Measures to Protect Privacy (KSA guidelines)
1. Make sure examination takes place in isolation from other patients, unauthorized family members, and/or staff 2. Provide gender-sensitive waiting and examination rooms 3. Provide proper clothing for the admitted patients 4. Make sure patients are well covered when transferred from one place to another in the hospital 5. Make sure your patient’s body is exposed ONLY as much as needed by the examination or investigation 6. Patients should have separate lifts and be given priority
Measures to Protect Privacy (KSA guidelines)
1. Make sure there is another person (nurse) of the same sex as the patient present all the time of the examination 2. Always take permission from the patient before examination 3. Insure privacy when taking information from patients 4. Avoid keeping patients for periods more than required by the procedure. 5. It’s prohibited to examine the patient in the corridors or in the waiting area. 6. During examination, no foreign person unrelated to the patient allowed 7. Give patients enough time to expose the part with pain 8. Only relevant personnel are allowed to enter the examination room
CONFIDENTIALITY
Why is there a Duty for Confidentiality?
• Trust between patients and health professionals. • Patients give information about their health in confidence. • Individuals will be encouraged to seek appropriate treatment and share information relevant to it.
What is Confidential? • All identifiable patient information, whether written, computerised, visually or audio recorded or simply held in the memory of health professionals, is subject to the duty of confidentiality. It covers: – The individual’s past, present or future physical or mental health or condition, – Any clinical information about an individual’s diagnosis or treatment; – A picture, photograph, video, audiotape or other images of the patient; – Who the patient’s doctor is and what clinics patients attend and when; – Anything else that may be used to identify patients directly or indirectly
Confidentiality Measures 1. Limit the accessibility to the medical records 2. Do not discuss the patient’s medical information with unauthorized family members 3. Do not disclose patient’s information without his/her consent, or in established exceptions (below) 4. Do NOT collect information not related to the provision of care 5. Set policies that regulate access to medical information and how any breach to confidentiality is managed 6. Limit sharing of information with other staff, unless in cases of consultations and second opinion
Confidentiality Measures …cont. All records • Never inappropriately access records; • Shut/lock doors, offices and filing cabinets; • Query the status of visitors/strangers; • Advise senior personnel if anything suspicious or worrying is noted; Manual records • Hold in secure storage; • Tracked if transferred, with a note of their current location within the filing system; • Returned to the filing system as soon as possible after use; • Stored closed when not in use so that the contents are not seen by others; • Kept on site unless removal is essential.
Confidentiality Measures …cont. Electronic records • Always log out of any computer system or application when work is finished; • Do not leave a terminal unattended and logged in; • Do not share Smartcards or passwords with others; • Change passwords at regular intervals to prevent others using them; • Always clear the screen of a previous patient’s information before seeing another. Email and fax • Whenever possible, clinical details should be separated from demographic data; • All data transmitted by email should be encrypted;
Proficiency (Medical) Secret • It includes any information that the doctor (or treatment team) knows about the patient (alive or dead), directly or indirectly that a patient may deem its disclosure undesirable or harmful to his/her health, reputation, financial, social or professional status. • It includes any information about the patient’s identity, condition, diagnosis, investigations’ results, treatment, and/or prognosis (whether chances of cure, disability, or death) (Source: https://sites.google.com/site/ghaiathme/medicaleducation/practitioner-1/practiti oner )
Conditions to Disclose Medical Secret 1. Approval from the patient or his/her SDM, within the limit given in the approval 2. If the information are required by judiciary {}ومن يكتمها فإنه آثم قلبه{ }ول يأب الشهداء إذا ما دعوا 3. Consultation or second opinion 4. Notification of events of public health interest/threats (birth, death, notifiable diseases, etc.) 5. Prevent individual/personal threats (crimes, STIs, ?) 6. If needed by the doctor to defend him/herself before judges, or discipline committee 7. ? “for the doctor to disclose some or all of the secret if she/he deems this necessary to the cure of the patient!”
Have You Ever Witnessed...? • A patient fully exposed in front of a dozen eyes and pairs of hands (rounds)? • A patient being photographed without consent? • A Couple of doctors chatting about their patients over lunch? • A doctor, who is a relative of the patient “having a look” in his relative's medical record? • A student approaching patients with questionnaires without consent or institutional approval? DON’T DO THAT...RESPECT YOUR PATIENT’S PRIVACY & CONFIDENTIALITY
Questions & Discussions • More information on the Medical ethics Course: https://sites.google.com/site/medicale thicscourse/
Professionalism and Ethics Education for Residents (PEER)
Privacy, Confidentiality and Medical Records Dr. Ghaiath M. A. Hussein
Asst. Prof., Dept. of Medical Ethics King Fahad Medical City – Faculty of Medicine King Saud Bin Abdul-Aziz University for Health
Outline Definitions and differences How to maintain the privacy of our patients? How to maintain the confidentiality of our patients’ information? When to disclose medical information
Privacy and ? Confidenciality
Confidentiality : Privacy:
- Is the right of an individual to have personal, identifiable medical information kept out of reach of others.
- A right or expectation to not be interfered with - Be free from surveillance - A moral right to be left RESPECTS PATIENT’S RESPECTS PATIENT’S alone. INFORMATION
BODY
PRIVACY
Measures to Protect Privacy (KSA guidelines)
1. Make sure examination takes place in isolation from other patients, unauthorized family members, and/or staff 2. Provide gender-sensitive waiting and examination rooms 3. Provide proper clothing for the admitted patients 4. Make sure patients are well covered when transferred from one place to another in the hospital 5. Make sure your patient’s body is exposed ONLY as much as needed by the examination or investigation 6. Patients should have separate lifts and be given priority
Measures to Protect Privacy (KSA guidelines)
1. Make sure there is another person (nurse) of the same sex as the patient present all the time of the examination 2. Always take permission from the patient before examination 3. Insure privacy when taking information from patients 4. Avoid keeping patients for periods more than required by the procedure. 5. It’s prohibited to examine the patient in the corridors or in the waiting area. 6. During examination, no foreign person unrelated to the patient allowed 7. Give patients enough time to expose the part with pain 8. Only relevant personnel are allowed to enter the examination room
CONFIDENTIALITY
Why is there a Duty for Confidentiality?
• Trust between patients and health professionals. • Patients give information about their health in confidence. • Individuals will be encouraged to seek appropriate treatment and share information relevant to it.
What is Confidential? • All identifiable patient information, whether written, computerised, visually or audio recorded or simply held in the memory of health professionals, is subject to the duty of confidentiality. It covers: – The individual’s past, present or future physical or mental health or condition, – Any clinical information about an individual’s diagnosis or treatment; – A picture, photograph, video, audiotape or other images of the patient; – Who the patient’s doctor is and what clinics patients attend and when; – Anything else that may be used to identify patients directly or indirectly
Confidentiality Measures 1. Limit the accessibility to the medical records 2. Do not discuss the patient’s medical information with unauthorized family members 3. Do not disclose patient’s information without his/her consent, or in established exceptions (below) 4. Do NOT collect information not related to the provision of care 5. Set policies that regulate access to medical information and how any breach to confidentiality is managed 6. Limit sharing of information with other staff, unless in cases of consultations and second opinion
Confidentiality Measures …cont. All records • Never inappropriately access records; • Shut/lock doors, offices and filing cabinets; • Query the status of visitors/strangers; • Advise senior personnel if anything suspicious or worrying is noted; Manual records • Hold in secure storage; • Tracked if transferred, with a note of their current location within the filing system; • Returned to the filing system as soon as possible after use; • Stored closed when not in use so that the contents are not seen by others; • Kept on site unless removal is essential.
Confidentiality Measures …cont. Electronic records • Always log out of any computer system or application when work is finished; • Do not leave a terminal unattended and logged in; • Do not share Smartcards or passwords with others; • Change passwords at regular intervals to prevent others using them; • Always clear the screen of a previous patient’s information before seeing another. Email and fax • Whenever possible, clinical details should be separated from demographic data; • All data transmitted by email should be encrypted;
Proficiency (Medical) Secret • It includes any information that the doctor (or treatment team) knows about the patient (alive or dead), directly or indirectly that a patient may deem its disclosure undesirable or harmful to his/her health, reputation, financial, social or professional status. • It includes any information about the patient’s identity, condition, diagnosis, investigations’ results, treatment, and/or prognosis (whether chances of cure, disability, or death) (Source: https://sites.google.com/site/ghaiathme/medicaleducation/practitioner-1/practiti oner )
Conditions to Disclose Medical Secret 1. Approval from the patient or his/her SDM, within the limit given in the approval 2. If the information are required by judiciary {}ومن يكتمها فإنه آثم قلبه{ }ول يأب الشهداء إذا ما دعوا 3. Consultation or second opinion 4. Notification of events of public health interest/threats (birth, death, notifiable diseases, etc.) 5. Prevent individual/personal threats (crimes, STIs, ?) 6. If needed by the doctor to defend him/herself before judges, or discipline committee 7. ? “for the doctor to disclose some or all of the secret if she/he deems this necessary to the cure of the patient!”
Have You Ever Witnessed...? • A patient fully exposed in front of a dozen eyes and pairs of hands (rounds)? • A patient being photographed without consent? • A Couple of doctors chatting about their patients over lunch? • A doctor, who is a relative of the patient “having a look” in his relative's medical record? • A student approaching patients with questionnaires without consent or institutional approval? DON’T DO THAT...RESPECT YOUR PATIENT’S PRIVACY & CONFIDENTIALITY
Questions & Discussions • More information on the Medical ethics Course: https://sites.google.com/site/medicale thicscourse/
