Ethics of medical records and professional communications.
In child and adolescent psychiatry, medical records and professional communications raise important ethical concerns for the treating or consulting clinician. Although a distinction may be drawn between internal records (eg, medical records and psychotherapy notes) and external communications (eg, consultation reports and correspondence with pediatricians), several ethical principles apply to both types of documentation; however, specific considerations may vary, depending upon the context in which the records or communications were produced. Special care is due with regard to thoroughness and honesty, collaboration and cooperation, autonomy and dignity of the patient, confidentiality of the patient and family members, maintaining objectivity and neutrality, electronic communications media, and professional activities (eg, political advocacy). This article reviews relevant ethical concerns for child and adolescent psychiatrists with respect to medical records and professional communications, drawing heavily from forensic and legal sources, and offers additional recommendations for further reading for clarification and direction on ethical dilemmas.
The Warren Alpert Medical School of Brown University, and Butler Hospital, 345 Blackstone Boulevard, Providence, RI 02906, USA. patricia_recupero@brown.edu
Patricia R
PR
Recupero
D000293:Adolescent; D000296:Adolescent Psychiatry / Q000941:ethics*; D002648:Child; D002665:Child Psychiatry / Q000941:ethics*; D003142:Communication; D003219:Confidentiality / Q000941:ethics; D003299:Cooperative Behavior; D034742:Electronic Mail / Q000941:ethics; D004992:Ethics, Medical; D006801:Humans; D008499:Medical Records; D010348:Patient Care Team / Q000941:ethics; D010358:Patient Participation; D026684:Personal Autonomy; D011368:Professional-Family Relations; D012017:Referral and Consultation / Q000941:ethics