Home Forums Discussions General Discussion Confidential Charting

A general question to those of you who have been using amazing charts for a while.
What is the best way to document something so that it remains confidential?

Here's my scenario:

I have a teenager who comes to our office with her mom for routine physicals, sick visits etc. She is now being seen for family planning and wishes it to remain confidential as she doesn't want her mom to know she came in for birth control. We can legally see her and provide family planning services.

My concern would be if for some reason there is a request for medical records, STD results could be sent or if something came back abnormal that a call would be made.
What's the best way to approach this with AC? I know there's the yellow note area in demographics.

The only thing I could think of was to make a separate chart in AC for only the confidential visits/results etc

Any suggestions???

I am very strict about NO adult information being shared with another person. This includes adult kids and their parents, husbands and wives,and so on. I would go over that again with the staff. Even to get your own records you have to sign a form and there is a check box for the staff member to make sure there is a release on the chart first. You could have the same problem with a husband calling to ask about his wife's results. You can use the FLAG section of AC for private information as well, but I don't know how you could hide a lab within the chart. You could have a paper file or an electronic file with scanned results, and say in the EHR: see classified file.

I think Chris is right. The answer is not found within the kind of record you have, be it electronic or paper. The flag will set confidential information, but is of limited use.. things like "This patient becomes violent if you mention his ex-wife"... things like that. Otherwise, I think you are in the same position you would be with paper. How would you handle contraception advice in a paper chart? I'd do it the same.

Maybe two charts is the answer, and start treating the second one as her adult chart. It would be interesting to hear how family practice doctors do this, who will see a patient from birth to adulthood. In my world, when a young person enters our practice, I make it clear to all concerned that I will be treating him/her as an adult and respecting his/her confidentiality regardless of age, but they are no longer really children by that point.

Marty, have you thought of using the "confidential" tab? There is some discussion about it here.

I too am very strict and do not share any information with any person without consent. Not even spouses etc.

Maybe I should have clarified, my scenario is about a 15 year old girl.

I appreciate the feedback

I think it is ironic that you can withold information, but bill parent and their insurance. Makes it difficult if the code for the office visit is contraceptive management ......

I agree with the others. We don't give out that info to anyone other than the patient (or the insurance companies when notes are required to be reviewed)

When a 15 year old enters my practice, as mentioned earlier, he/she gets the confidentiality rights of an adult, and both the patient and parent need to agree. It is also the deal my wife and I made with our 14 year old's doctor.. I do not know how I would handle a patient who starts as a baby and ages; clearly a 3 year old's parents need to know everything. I'd like to hear more. Do you FP guys set an arbitrary age, follow some state law invariably, have a chat with the patient and parents when you think the time has come to treat him/her more as an adult, "wing it", or what?

In FP-land, there is a magic age between 13-21 where the parent accompanies the minor/adult-child to a wellness visit and says to the minor/adult-child "would you like me to leave so you can talk to Dr. Lauer alone?" Or the minor comes in for the first time for a sinus infection unaccompanied by the parent and has driven themselves to our office with a newly acquired driver's license.

I take these opportunities to say, "you (the minor) are growing up and will have personal and confidential things you need to share with me. While it's best to be open with your parents, there are some things that need to be discussed in private. I add that parents have a legal right as the parent of said minor to see their medical record." And I look at the parent to say "but we discourage this practice b/c it undermines the confidential and trusting nature of the doctor-patient relationship." The parent always nods their head in agreement. Then I say to the minor "if you have serious things to say, I hope you can trust your parents to listen and help rather than get mad." Then I look at the parents and say "Right?" And go on to say "But if you ever need to share things with me, I promise not to disclose this information with your parents unless you have agreed to let me share it. I look at the parents for the confirmatory head-nod.

We have not had the experience where a parent demands the minor's chart to search for confidential information. I hope we never do.

Adam,

I think that's a great approach.

Perfect.

And, Adam, that kind of brings us full circle. Do you do something different in the chart to note that this threshold has been passed, or is your memory just a lot better than mine? Or, do you just "know?"

I also realize that there is some flexibility in all this for me, more than some of the posts above might suggest. Example: a spouse is in the waiting room, to pick up a patient in whom I have just discovered something really bad. I will usually bring him/her into the recovery room to break the news to both of them at once, figuring the mutual support trumps confidentiality.

Personally I work on the assumption that if the patient wants the spouse/sibling/parent/friend in the room, then that is specific approval to divulge the PHI to that person as I speak with the patient. If I have any doubt, of course, I ask first.
If the patient is not present, and I have not gotten persmission from the patient, I pull a Sgt Schutz: "I know nothing!!!"

Roger,

I've work off the same assumption as you do when someone brings their significant other into the exam room with them. To me that is consent. I had one issue once where a patient got upset that I talked about an issue that she didn't want her partner to know about (and that's what the visit was about). While I understood she was upset, I pointed out to her that if she didn't want her boyfriend to know than why did she bring him to the appointment to discuss the results?

Marty,

Let me throw another perspective into the mix. You started the conversation by talking about seeing a 15yo and prescribing BCP without the parent's knowledge. Would you prescribe Accutane or Zoloft or any other drug without informing the parents? This idea that doctor-patient confidentiality should supercede parental authority is very problematic. And yes, I know I'm a Luddite! :-) But if you respected parental authority, you wouldn't be having this confidentiality dilemma.

John, that was, I think, the point of the initial question. In some states, a 15 yo can get contraception without parental authority, and many of us would feel that doing so has the higher priority. The question is, how to chart it.

David got it right. The initial point of the thread has nothing to do with parental authority.

My question really was what's the best way to chart something that is confidential.

Funny how a thread can change

Dave,
I do not document this status anywhere in the chart.
It's something I remember.

If I were a pediatrician, I would probably document this somewhere or take a different approach entirely. But in my practice, it's largely made of adults and maybe 10% peds. So it's not massive numbers of people to keep straight.

The best way to keep information confidential is to keep it totally separate from AC--or even better, not to have any written record. I am especially referring to intensely personal information that patients sometimes reveal to us. As others have commented in other threads, over time EMR's will be available to more and more people (insurance, medical, government). Yet, in this case, the 15yo prescribed BCP, if you write such a prescription, I don't think you have any choice but to document the prescription in the chart.

It's interesting, the same exact type of case was recently reported in the AMA Journal of Ethics. It doesn't seem that it is possible to keep this information completely confidential unless the adolescent is emancipated, since the parent will be informed of the diagnosis or treatment by insurance.

I guess I am more worried about making a mistake with patient care than with the legal hassles.

To me it seems that the greatest burden is to make sure that the patient suffers no harm, even though this is a minefield. I practice with assistants, and it could be dangerous for the patient if we are not all aware of confidential information. That data should be obvious in the electronic record so it will be a part of every decision it could affect.

In Marty's scenario, what if the other provider doesn't know of the birth control pills and prescribes an antibiotic and you have a pregnancy. Unlikely since the med list has the OCP, if you are prescribing. But it needs to be on the med list even if you aren't prescribing. That kind of information cannot be kept in a hidden place.

If someone says they are bisexual or homosexual and want it confidential, I wouldn't put it anywhere in the chart, since it doesn't matter. If they say they have high risk behaviors, I think that has to be charted to keep in your perspective at every visit.

But then this subject is one of those reasons I wasn't capable of dealing with pediatrics.

I agree with Dan - I discuss with child - I don't have parents demand records, but that could be a problem I suppose. The danger is if you don't record it then how does that affect care in the future.

In our office, I have started to scan in all the HIPPA forms completed by the patient. It is filed with the non-medical so it doesn't need to be signed off. I title it HIPPA FORM so that it will stand out. Any time we receive a call, we check this to confirm the patients wishes. If there is a change, the patient completes a new HIPPA form and the chart is updated. Most of our patients are adults. We have a few minors. Since we are family practice, we have not had any issues with minors requesting birth-control. I believe most in this area go to planned parenthood or an obgyn.

Unfortunately minors do tend to go to planned parenthood and the like in the city - which makes it more problematic as they don't tell you they are on the medicine which could cause issues. In small towns they are more likely to talk to the doc - great thing is that many, many parents want me to prescribe birth control, etc as our world is changing and even though we try to teach our children we also need to have realistic views of what our chilren are doing.

I found this report kind of interesting:

Results: Overall, the teenagers in the sample had a median age at first sex of 16.9 years. Black males had the lowest observed median (15.0), and Asian American males the highest (18.1); white and Hispanic males, and white and black females, reported similar ages (about 16.5 years). Hispanic and Asian American females had rates of first sex about half that of white females, although these protective effects were explained by differences in family structure. Even after controlling for background characteristics, black males had rates of first sex that were about 3-5 times the rates of the other gender-and-ethnicity groups. In addition, Asian American males were less likely than Hispanic males to be sexually experienced, and Hispanic males had almost twice the rates of sexual activity of Hispanic females.

-- Guttmacher institute