Patients as Medical Record Keepers


A number of concerns have been raised by the medical community about giving patients control of their own version of their medical record.   Patients may elect to redact certain information from their medical records that they may view as sensitive (e.g., mental health history, history of drug and/or alcohol use, sexually transmitted diseases, etc.).  This has the potential to compromise the clinical record and hence clinical care.  However, it is extremely common for patients to present to clinicians for evaluation without any medical records. At that point the history must be taken directly from the patient.  Patients may again elect not to share sensitive information with the provider during the process of providing a verbal history.This is not considered to be outside the realm of typical patient care

The majority of patients would not remove information from the records they are maintaining.  In contrast, they have the time and motivation to assemble the entire record of care across the entire healthcare ecosystem.  These compiled records can then be presented to a treating physician and are likely to be far superior to having no records whatsoever during a patient encounter.  The provider will know that the records have been maintained by the patient and will need to maintain awareness that the information provided may not be complete and accurate.  .

In summary, allowing patients to maintain and edit their own medical records is no worse than relying on patients to provide an accurate history during a patient encounter.  It also allows the patient to provide a highly complete clinical record to a treating physician.  Providers will need to maintain awareness that some patients may elect to modify information in the record,  However, the advantages of allowing patients to maintain their own records greatly outweighs the inherent disadvantages of having an incomplete or absent record.

The information in this post represents the opinions of Dr. Michael Stearns