Keeping joint medical and nursing notes at foot of bed

BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7235.646 (Published 04 March 2000) Cite this as: BMJ 2000;320:646

What about confidentiality if notes can be accessed by anybody?

  1. Jose Catalan (j.catalan{at}ic.ac.uk), reader in psychiatry
  1. Imperial College, Psychological Medicine, Chelsea and Westminster Hospital, London SW10 9NG
  2. Redbridge Health Care Trust, King George Hospital, Ilford, Essex IG3 8YB
  3. North Middlesex Hospital, London N18 1QX
  4. Royal Free Hospital Hampstead NHS Trust, London NW3 2QG

    EDITOR—Luke et al's report on the views of patients' families and staff on the placing of notes at the foot of the bed shows some advantages of promoting partnerships in health care.1 The authors hint at but unfortunately do not address some difficulties with patients' autonomy, confidentiality, and the content of records, all of which require further consideration.

    There are substantial differences between patients and within the same patient at different times in terms of attitudes to patient autonomy.2 3 A blanket policy of making records available to patients without first inquiring about their wishes or explaining the significance of the options listed in a differential diagnosis or test results would be the opposite of a patient centred approach. Staff often misjudge patients' wishes for information and involvement in decisions, 2 3 and direct communication between the parties seems the simplest route to reaching agreement.

    The question of who else besides the patient might be able to browse through the case notes needs to be considered: should information about termination of pregnancy, psychiatric treatment, or HIV testing be accessible to partners, relatives, and visitors? Patients would need to be fully aware of the contents of their case notes before agreeing to making them potentially available to others.

    Patients' access to health records is regulated by the Access to Health Records Act 1990, and refusal to disclose information is possible if the health professional is satisfied that serious physical and mental harm can occur. Whether entries in the case notes and correspondence from third parties should be automatically accessible to patients without the consent of the author of the communication is questionable. As a general hospital psychiatrist, I routinely write in the case notes of patients seen for consultation and correspond with doctors who have referred them; I would wish to be asked before my assessment and management advice were made available to patients. Alternatively, case notes could be screened and third party or potentially harmful communications removed, but this would lead to two sets of records (confidential and super-confidential?), which would defeat the object of the exercise.

    New technologies in the form of electronic records and PINs (personal identification numbers) allowing patients access to health records may well provide answers to some of these difficulties and new challenges. They will not, however, do away with the need for healthcare workers to communicate directly with their patients to find out how much they already know or wish to learn about their health, to keep them involved in decisions about treatment, and to ensure that a true partnership develops.


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    Authors' reply

    1. S G M Luke, consultant paediatrician,
    2. A Gallagher, clinical nurse specialist,
    3. B W Lloyd (blloyd{at}rfhsm.ac.uk), consultant paediatrician
    1. Imperial College, Psychological Medicine, Chelsea and Westminster Hospital, London SW10 9NG
    2. Redbridge Health Care Trust, King George Hospital, Ilford, Essex IG3 8YB
    3. North Middlesex Hospital, London N18 1QX
    4. Royal Free Hospital Hampstead NHS Trust, London NW3 2QG

      EDITOR—We agree with Catalan that the results of our study on a general paediatric ward cannot automatically be generalised to other settings. We would reassure him that families are aware of what is in the notes that are placed at the end of the bed. This is partly because the notes are written in the family's presence and partly because the family can read what has been written. The families are told that the normal practice is to keep the notes at the foot of the bed. Occasionally parents have asked that the notes be kept on the trolley in the ward office.

      It is only the notes concerning the current admission that are kept at the foot of the bed. The hospital folder containing the old medical notes are kept in a trolley in the ward office. Any healthcare professional can choose whether the child's interests are best served by them writing their comments in the notes at the foot of the bed or on a sheet in the main hospital folder. It is unusual for professionals, other than healthcare professionals or social workers, to write their notes in the main folder rather than in the folder at the foot of the bed. The main occasions are when there are child protection concerns, when the patient is a disturbed adolescent, or when an adolescent does not wish his or her parents to have access to information shared with medical or nursing staff.

      We have found that, because doctors and nurses know that the family is likely to read their notes, they not only think carefully before they write but are also more likely to talk to the family about what they have written. The system of keeping the notes at the foot of the bed on the children's ward continues to evolve at North Middlesex Hospital. The disadvantages seem to be largely theoretical and to be greatly outweighed by the benefits of openness and partnership.

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