Reasonable for Psychiatrist to Decline Patient’s Request to Remove Parts of Medical History and for Sharing Information with Others in Patient’s Circle of Care

A patient complained about the conduct of a psychiatrist, stating that the psychiatrist wrote false information in the patient’s medical records, but would not amend it. The patient also complained that the psychiatrist breached her confidentiality by providing these records to her family doctor.

The Health Professions Appeal and Review Board (the “Board”) confirmed the decision of the Inquiries, Complaints and Reports Committee of the College of Physicians and Surgeons of Ontario (the “Committee”) to take no further action.

Background

The patient was referred to the psychiatrist by her family doctor and was treated by the psychiatrist from 2011-2013. In 2015, the patient was involved in a car crash and her lawyer requested her medical records from her family doctor. At this time, she discovered that the records contained notes of the psychiatrist’s assessment. The patient advised the psychiatrist that notes in the records regarding her suicidal ideation and a family member’s suicide were incorrect and asked for the entries to be amended. The psychiatrist refused to do so but added an addendum stating that the patient denied her father’s attempted suicide.

The Committee

The Committee decided to take no further action, noting that the College of Physicians and Surgeons’ confidentiality policy (the “Policy”) states that physicians may share information with others involved in the patient’s circle of care unless the patient has withdrawn or withheld consent. The family physician is in the patient’s circle of care and consent was not withdrawn or withheld. However, the Committee noted that it would be prudent for physicians to discuss this practice with their patients.

Also, the Committee held that it was reasonable for the psychiatrist to have declined to amend his records regarding the patient’s suicidal ideations and to have issued an addendum to clarify the notes regarding the patient’s father.

The Board

The Board’s mandate is to consider either the adequacy of the Committee’s investigation, the reasonableness of its decision, or both. An investigation does not need to be exhaustive but the essential information must be obtained to make an informed decision. The Board agreed that the investigation was adequate.

On the issue of reasonableness, the question was whether the Committee’s decision could be reasonably supported by the information before it and can withstand a somewhat probing examination. The Board considered whether the decision falls within a range of possible outcomes that are defensible with respect to the facts and law. In this case, the Board found that the Committee reached a reasonable decision given the Policy regarding information sharing, noted above. The patient’s family physician is in her circle of care and the psychiatrist would be expected to share information regarding the patient with the family physician. There was no information on record stating that the patient told the psychiatrist she did not want him to share information with her family doctor. However, the Board endorsed the Committee’s comment that it would be prudent for doctors to discuss the standard practice of information sharing with referring physicians with patients.

The Board also found that it was reasonable for the Committee to find that the psychiatrist acted appropriately in declining to amend the notes with respect to the patient’s suicidal ideations, which was included in several places. Regarding the notation about the patient’s father, however, the psychiatrist acted appropriately in writing the clarifying addendum.

Takeaway

Physicians may share information with others involved in the patient’s circle of care unless the patient has withdrawn or withheld consent. However, it would be prudent for physicians to discuss this practice of information sharing with their patients. As well, if a patient wishes to correct a record, this should be done if the patient can demonstrate, to the professional’s satisfaction, that the record is incomplete or inaccurate for the purpose However, health professionals are not required to change their professional opinions and of course, they should not correct a record that they did not create. What should occur, is what happened in this case, is to either issue a clarifying addendum or allow the patient to add their own note to the file.

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