In een bericht met de datum 14-12-2007 21:13:21 West-Europa (standaardtijd), schrijft jpfreriks at gmail.com:
Dear Josina, This question should perhaps be in the openEHR legal list serve :-) >From the clinical point of view I understand your question. However, the two use cases differ 180 degrees. The cancer use case is according to Dutch law at the edge of illegality. A Doctor is not allowed to not enter objective patient data in the record. He is allowed to keep personal notes on the cancer, but the moment he enters this information as reason for a labtest it should be disclosed to the patient. Anyway, the patronazing approach with respect to cancer has been left for over 25 years now. The information about a relative which comes to attention of a doctor (health professional) must be kept confidential for the patient. Here it would be illegal to disclose it, aside from the medical implications. the believing a patient or not can be handled in the problem oriented medical record. Dutch GP's use subjective, objective, evaluation, plan. The easy way forward is to list the subjective things a patient tells and to balance that in the objective. using the wording like i do not believe him/her is perhaps not appropriate in the medical record. So if you want a technical solution, the two totally distinct use cases need to be addressed differently. In a functional requitement set we made a separate section for care professionals to keep confidential notes. This is then not attached to the individual patient's record, but is only accesible to this one person the doctor making the personal note (so not to other professionals). William > > Hello, > > I posted this message to the clinical mailing list, but think this should be > on the technical mailing list. Apologies if I'm not correct (and please a > further explanation about what is meant by 'technical' ;-) ) > > I've got a question about Author Information Mandate. (an issue also > brought up under 'Archetype production: Types of Archetypes' by Gerard > Freriks.) > > What is determined about the access control of information documented by the > physician that s/he wants to keep obscured from the patient? I believe that > the whole care process is characterised by a the subtle ?game? between > physician and patient, where the physician has its private thoughts and goals > (which he wants to document) but doesn?t want the patient to know, or only > partly. For instance, a GP might be quite sure the patient has cancer but > doesn?t > want to alarm the patient right away so orders blood tests. (There surely are > medically more correct examples.) Others are i.e. whether the physician > believes the patient or not, or when the physician has got extra information > conveyed by a relative that the patient mustn?t know about. It is harmful to > the > care process and the physician-patient relation if the patient has access to > all of this. > Is there a way, in the RM for instance, that everything that is under > EVALUATION is kept hidden from the patient? I think this should be so. There > should > be ?according to my opinion ? two separate parts in the EHR: a shared part > (open to, and access controlled by the patient) and a private part containing > the physicians evaluations and comments. This latter part should only be > made visible to the patient under certain (legal) circumstances, where the > patient can order to delete certain info. > My question: has this been taken care of right now? If so: how? > > Sincerely yours, dr. William TF Goossen director Results 4 Care b.v. De Stinse 15 3823 VM Amersfoort email: Results4Care at cs.com phone + 31654614458 fax +3133 2570169 Dutch Chamber of Commerce number: 32121206 </HTML> -------------- next part -------------- An HTML attachment was scrubbed... URL: <http://lists.openehr.org/mailman/private/openehr-technical_lists.openehr.org/attachments/20071215/91c3a459/attachment.html>
