A retrospective analysis revealed that most patient requests to amend medical records were for the purpose of correcting inaccuracies, but 6.6% of the requests involved removing accurate information.
In the current climate of increasing transparency, physicians may encounter requests from patients to modify or withhold essential medical information from their electronic medical records. According to the Health Insurance Portability and Accountability Act (HIPAA), patients have the right to view their medical records and request amendments. However, physicians hold the final authority over the inclusion of information, guided by the principles of beneficence and nonmaleficence. Omitting medically pertinent history can result in patient harm.
In the analysis, published in Clinics in Dermatology, researchers provided a framework focusing on ethical principles such as truthfulness, privacy, beneficence, nonmaleficence, and autonomy.
One case study detailed a patient with palmoplantar pustulosis who requested the omission of her smoking status from her electronic medical record to qualify for surgery. This omission could compromise her surgical outcome, thus contravening the ethical obligations of truthfulness and nonmaleficence. Physicians were advised to ensure that critical information is accurately documented and communicate to patients the risks associated with omitting such information.
Another case involved a patient with chronic cutaneous lupus erythematosus who requested a physician exclude information about his blurry vision from his medical record as a result of concerns about job security.
Patients may seek omissions because of various concerns such as embarrassment, insurance or employment issues, or protecting family members. Physicians should discuss with patients the potential harm caused by omitting relevant medical information and explain why it is essential to include all necessary details in their medical records.
While respecting patient autonomy and privacy, physicians must prioritize the accuracy of medical records to prevent harm and facilitate effective communication among health care providers. Educating patients on these ethical principles can help them understand the necessity of including all relevant information in their electronic medical records. The researchers concluded that accurate health information is crucial for the integrity of medical records, mandated by many states, and vital for patient welfare.
The authors reported no potential conflict of interest.
