When is a medical record not a medical record?

N Z Med J. 2013 Oct 18;126(1384):109-17.

Why a shared care record is an official medical record.

Gu Y, Orr M, Warren J, Humphrey G, Day K, Tibby S, Fitzpatrick J.

Source

National Institute for Health Innovation, University of Auckland, Private Bag 92019, Auckland, New Zealand. h.gu@auckland.ac.nz.

Abstract

The literature describes three categories of health records: the Official Medical Records held by healthcare providers, Personal Health Records owned by patients, and--a possible in between case--the Shared Care Record. New complications and challenges arise with electronic storage of this latter class of record; for instance, an electronic shared care record may have multiple authors, which presents challenges regarding the roles and responsibilities for record-keeping. This article discusses the definitions and implementations of official medical records, personal health records and shared care records. We also consider the case of a New Zealand pilot of developing and implementing a shared care record in the National Shared Care Planning Programme. The nature and purpose of an official medical record remains the same whether in paper or electronic form. We maintain that a shared care record is an official medical record; it is not a personal health record that is owned and controlled by patients, although it is able to be viewed and interacted with by patients. A shared care record needs to meet the same criteria for medico-legal and ethical duties in the delivery of shared care as pertain to any official medical record.