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Patient Rights and Confidentiality Policy

Green Mountain Internal Medicine, PLC

Melissa Brandes M.D.

28 S. Williams St. Burlington, VT 05401

Phone 802-864-7080/ FAX 802-863-0411

 

Patient Rights and Confidentiality Policy

Principal

Confidentiality is a fundamental tenet of Medical Care. It is a matter of respecting the privacy of the patients, encouraging them to seek medical care and discuss their problems candidly, and preventing discrimination on the basis of their medical conditions.  This policy applies to all staff working at the above site. The physician and office staff in this practice have read and agreed to the following guidelines.

Guidelines

Confidentiality:   The physician and office staff must not release information without the patient’s consent (often termed a “privileged communication”).   However, confidentiality like other ethical duties, is not absolute. It may have to be overridden to protect individual persons or the public.  For example, to warn sexual partners that a patient has syphilis or is infected with HIV, or to disclose information when the law requires it. Before breaching confidentiality, The physician should make every effort to discuss the issues with the patient. If breaching confidentiality is necessary, it should be done in a way that minimizes harm to the patient and that heeds applicable federal and state law. Discussion of the problems of an identified patient by professional staff in public places (For example, in elevators or in cafeterias) violates confidentiality and is unethical.

Patient information (both paper and computerized records) must be safeguarded to prevent breach of confidentiality. All paper records shall be kept in a restricted office area which cannot be accessed directly by patients or the general public. All computer records shall be maintained on computers which may be accessed only by the physician and authorized office staff. The physician and office staff shall not allow any patient information to be left in an area accessible by the General Public.  Our computer record is a shared electronic record with UVM Medical Center. Safeguards including regular audits prevent hospital and office staff from accessing patient data when they are not directly involved in a particular patient’s care.

The patient and the Medical Record: patients have the right to know what is in their medical records. Legally, the actual chart is the property of the physician, although the information in the chart is the property of the patient. The physician must release information to the patient or to a third party at the request of the patient. Physicians should retain the original of the chart and radiographic studies and respond to a patient’s request with copies unless the original record is required by law. To protect confidentiality, information should only be released with the written permission of the patient or the patient’s legally authorized representative.

Disclosure:   To make Healthcare decisions and work intelligently in partnership with the physician, the patient must be well informed. However uncomfortable to clinician or patient, information that is essential to the patient must be disclosed. Information should be given in terms that the patient can understand. The physician should be sensitive to the patient’s responses in setting the pace of disclosure, particularly if the illness is very serious. Disclosure should never be a mechanical or perfunctory process. Upsetting news and information should be presented to the patient in a way that minimizes distress. If the patient is unable to comprehend his or her condition, it should be fully disclosed to an appropriate surrogate.

In addition, physicians should disclose to patients information about procedural or judgment errors made either in the course of care if such information is material to the patient’s well-being. Errors do not necessarily constitute improper, negligent, or unethical behavior, but failure to disclose them may.