Saudi Commission for Health SpecialtiesProfessionalism and Ethics Education for Residents (PEER)

Privacy, Confidentiality and Medical Records

Dr. Ghaiath M. A. HusseinAsst. Prof., Dept. of Medical EthicsAlfarabi Colleges (Riyadh)

Disclaimer

• This presentation is based on a presentation I gave for the SCHS as part of its Professionalism and Ethics Education for Residents (PEER), available at: https://www.youtube.com/watch?v=b-7DOqRPqx0

• https://www.youtube.com/watch?v=OcQYe99SwSo

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 ?EXERCISE.…

Confidentiality :- Is the right of an individual

to have personal, identifiable medical information kept out of reach of others.

Privacy:- A right or expectation to not be interfered with - Be free from surveillance - A moral right to be left alone.

RESPECTS PATIENT’S BODY

RESPECTS PATIENT’S INFORMATION

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 rooms3. Provide proper clothing for the admitted patients4. Make sure patients are well covered when transferred from

one place to another in the hospital5. Make sure your patient’s body is exposed ONLY as much as

needed by the examination or investigation6. 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 examination3. Insure privacy when taking information from patients4. 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

allowed7. Give patients enough time to expose the part with pain8. Only relevant personnel are allowed to enter the examination room

CONFIDENTIALITY

Confidentiality Public Trust Seek healthcare

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.

Proficiency (Medical) Secret• Medical secret is defined as “Any medical information that

comes to the knowledge of the practitioners as a result of their work whether directly obtained from the patient, or otherwise”

• 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/practitioner)

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– The past, present, or future payment for the provision of health care to

the individual,

Confidentiality Measures

1. Limit the accessibility to the medical records2. Do not discuss the patient’s medical information with

unauthorized family members3. 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 care5. Set policies that regulate access to medical information

and how any breach to confidentiality is managed6. 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;

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;• 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

Conditions to Disclose Medical Secret1. Approval from the patients or their SDM, within the limit given in

the approval2. If the information are required by judiciary { إذا الشهداء يأب وال

دعوا } {ما قلبه آثم فإنه يكتمها {ومن3. Consultation or second opinion4. Notification of events of public health interest/threats (birth,

death, notifiable diseases, etc.)5. Prevent individual/personal threats (e.g. prevent crimes)6. If needed by the doctor to defend him/herself before judges, or

discipline committee7. If the patient consciously and truly admits committing a crime on

which another person was accused/punishedRemember: Disclosure should be only to the concerned party & not

beyond the needed limits سر الطبيبعن كشف أو الضابطفيستر أن الشريعة فقهاء أوضحالمفسدة ظهور منع المريضهو

Fiqhi & Legal Aspects�نتم" • و�أ �اتكم �م�ان أ �خونوا و�ت سول� و�الر ه� الل �خونوا ت ال� آم�نوا ذين� ال ه�ا �ي أ �ا ي

�مون� ) �عل ("27ت• (( : إذا قال وسلم، عليه الله صلى بي الن عن عنه الله رضي جابر عن

 )) داود أبو رواه ة أمان فهي التفت ثم بالحديث الرجل حدثااللباني وحسنه والترمذي

• To consider the disclosure of medical secret a crime, there are 4 conditions: الطبي السر افشاء جريمة أركان

1. Medical secret الطبي i.e. what was disclosed was a , السرsecret

2. The actual disclosure اإلفشاء regardless the way of فعلdisclosure

3. To be the person trusted to keep the secret يكون أنالسر على أمينا .المفشي

4. The intention to disclose ( الجنائي e.g. not out of ,.(القصدnegligence or forgetting, e.g. leaving the records open or accidently dropping a medical information sheet

ETHICS OF MEDICAL RECORDS

Ethics of Documentation and Authentication (Saudi Code of Ethics)

• They should document each procedure that he/she follows with the patient in accurate records, and strive to be accurate when writing medical reports, in a way that achieves the interest of the patient.

• They should write what is the true reality without exaggeration or underestimation and should not be taken astray by the bonds of kinship, passion, fear or desire of benefit to write a medical report that is untrue.

In Saudi Code of Ethics, the medical record should contain:• Appropriate clinical findings, • Decisions and procedures made, • The information given to the patient, • Prescriptions or medications, as well as • All the patient’s investigations

(A) Medical Record1. There should keep clear and precise paper and electronic

records for the patients.2. The medical record should be kept in a safe place, and

should not be accessed or handled unless by those who are professionally-related (to the patients) persons,

3. All the procedures related to professional confidentiality apply to all its contents.

4. All the contents of the medical record are the property of the institution in which the patient is receiving his/her treatment, but

5. The patient can have access to the record and have a copy of it upon his/her request.

(A) Medical Record4. In the event of referring a patient to another doctor,

the healthcare practitioner should provide for the referred healthcare practitioner all the information needed about the patient’s condition precisely and objectively.

5. When writing the data and information, scientific and administrative standards should be followed when writing, and have every document related to the medical record signed and dated.

(B) Certificates and Reports• Doctors enjoy the authority to sign a variety of documents

that lead to grave consequences if they are abused, including:– death certificates, – medical reports, – sick leaves, – certificates of patients’ attendance and others.

• Therefore, doctors have to ensure the correctness of the information before signing any document.

• Documents that are thought to be fake, false, or misleading should not be signed, instead follow the recognized scientific and administrative standards.

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