Indonesian Doctor’s Competence Indonesian Doctor’s Competence StandardStandard

(Konsil Kedokteran Indonesia, 2007)(Konsil Kedokteran Indonesia, 2007)

Competency areas:1. Effective communication2. Clinical Skill3. Scientific based medical sciences 4. Health problem management 5. Information management6. Self evaluation and development 7. Ethics, Moral, Medicolegal,

Proffesionalism and Patients safety

Informed consentInformed consent is a legal condition whereby a

person can be said to have given consent based upon an appreciation and understanding of the facts and

implications of an action. The individual needs to be in possession of relevant facts and also of his or her reasoning faculties, such as not being mentally

retarded or mentally ill and without an impairment of judgment at the time of consenting. Such impairments might include illness, intoxication, insufficient sleep,

and other health problems.

• Some acts cannot legally take place because of a lack of informed consent. In cases where an individual is considered unable to give informed consent, another person is generally authorized to give consent on their behalf. Examples of this include the parents or legal guardians of a child and caregivers for the mentally ill.

• In cases where an individual is provided limited facts, serious ethical issues may arise. Examples of this in a clinical trial in medical research are anticipated and prevented by an ethics committee or Institutional Review Board.

HAK ASASI MANUSIA (HAM)

• United Nations Declarations of Human Rights, 1948: “Setiap manusia berhak untuk dihargai, diakui, dihormati sebagai manusia dan diperlakukan secara manusiawi, sesuai dengan harkat dan martabatnya sebagai Mahluk Tuhan”

• B. Cardozo (1914): “Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performes an operation without his patient’s consent commits an assault, for wich he is liable in damages”

Issues surrounding assessment of consent

• Informed consent can be complex to evaluate, because neither expressions of consent, nor expressions of understanding of implications, necessarily mean that full adult consent was in fact given, nor that full comprehension of relevant issues is internally digested.

• Many times consent is implied within the usual subtleties of human communication, rather than explicitly negotiated verbally or in writing. In some cases consent is legally prevented from ever being possible, even if the person protests they do indeed understand and wish. There are also structured instruments for evaluating capacity to give informed consent, although no ideal instrument presently exists.

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HUBUNGAN DOKTER - PASIEN

Memperoleh Persetujuan

Dalam setiap tindakan yang akan dilakukan, dokter harus

mendapat persetujuan pasien, krn prinsipnya yang

berhak memberikan persetujuan atau penolakan

tindakan medis adalah pasien yang bersangkutan.

Dokter hrs yakin bahwa pasien mengerti tetang apa yg

disampaikan, shg dalam memberikan persetujuan tanpa

adanya paksaan atau tekanan

• There is thus always a degree to which informed consent must be assumed or inferred based upon observation, or knowledge, or legal reliance. This especially is the case in sexual or relational issues. In medical or formal circumstances explicit agreement by means of signature which may normally be relied upon legally, regardless of actual consent, is the norm.

Brief examples of each of the above:

• A person may verbally agree to something from fear, perceived social pressure, or psychological difficulty in asserting their true feelings. The person requesting the action may honestly be unaware of this and believe the consent is genuine, and rely upon it. Consent is expressed, but not internally given.

• A person may state they understand the implications of some action, as part of their consent, but in fact have failed to appreciate the possible consequences fully and later deny the validity of their consent for this reason. Understanding needed for informed consent is stated to be present but is in fact (through ignorance) not present.

• A person may move from friendship to sexual contact on the basis of body language and apparent receptivity, but very few people on a date that results in sexual contact have explicitly asked the other if their consent is informed, if they do in fact fully understand what is implied, and all potential conditions or results. Informed consent is implied (or assumed unless disproved) but not stated explicitly.

• A person below the age of consent may agree to sex, knowing all the consequences, but their consent is deemed invalid as they are deemed to be a child unaware of the issues and thus incapable of being informed consent. Individual is barred from legally giving informed consent, despite what they may feel

• In some countries (notably the United Kingdom), individuals may not consent to injuries inflicted upon them, and so a person practicing sadism and masochism upon a consenting partner may be deemed to have caused actual bodily harm without consent, actual consent notwithstanding. Individual is barred from legally giving informed consent, despite what they may feel (2). See also Spanner case and 'consensual non-consensuality'.

• A person signs a legal release form for a medical procedure, and later feels they did not really consent. Unless they can show actual misinformation, the release is usually persuasive or conclusive in law, in that the clinician may rely legally upon it for consent. In formal circumstances, a written consent will usually legally override later denial of informed consent (unless obtained by misrepresentation)

1. Ada indikasi medis untuk mencapai tujuan yg konkrit

2. Dilakukan menurut aturan yg berlaku dlm Ilmu Kedokteran ( Lege Artis )

3. Mendapat persetujuan lebih dahulu dari pasien ( Informed Consent )

Suatu tindakan medis tidak bertentangan dg hukum, bila:

INFORMED CONSENT/CHOICEPersetujuan yang diberikan seseorang yang kompeten sesudah menerima dan memahami penjelasan yang diberikan oleh dokter (dlm konteks profesi), dan membuat keputusan tanpa paksaan atau dipengaruhi secara berlebihan, dibujuk, dipaksa, atau diintimidasiDibuat secara tertulis dengan diperkuat oleh paling sedikit seorang saksi

A person or institution (e.g. a school or childcare professional) exposes a minor to non-age-appropriate material, in any media format, without the expressed informed consent of the minor's parent or legal guardian. Informed consent in this instance goes to the argument of competency on the part of the minor. An example would be the showing of an R rated movie to a 12 year old by an educational institution without the informed consent of the parent or legal guardian.

ISI PENJELASAN :

1. Pertimbangan, penilaian, maksud dan tujuan dokter 2. Keadaan yang menyangkut diri pasien 3. Risiko dari prosedur tindakan medis 4. Alternatif lain, bila ada 5. Konsekuensi bila tindakan medis itu tidak dilakukan

Yang berhak menandatangani?Dalam keadaan darurat?

Surgery

• The doctrine of informed consent relates to professional negligence and establishes a breach of the duty of care owed to the patient.

• In the United Kingdom and countries such as Malaysia and Singapore, informed consent requires proof as to the standard of care to be expected as a recognised standard of acceptable professional practice (the Bolam Test), that is, what risks would a medical professional usually disclose in the circumstances. Arguably, this is "sufficient consent" rather than "informed consent."

• In the United States, Australia, and Canada, a more patient-centered approach is taken and this approach is usually what is meant by the phrase "informed consent." Informed consent in these jurisdictions requires that significant risks be disclosed, as well as risks which would be of particular importance to that patient. This approach combines an objective (the reasonable patient) and subjective (this particular patient) approach.

• The doctrine of informed consent should be contrasted with the general doctrine of medical consent, which applies to assault or battery. The consent standard here is only that the person understands, in general terms, the nature of and purpose of the intended intervention.

• As the higher standard of informed consent applies to negligence, not battery, the other elements of negligence must be made out. Significantly, causation must be shown: that had the individual been made aware of the risk they would not have proceeded with the operation (or perhaps with that surgeon).

• The informed consent doctrine is generally implemented through good healthcare practice: pre-operation discussions with patients and the use of medical consent forms in hospitals. However, reliance on a signed form should not undermine the basis of the doctrine in giving the patient an opportunity to weigh and respond to the risk. In one British case, a doctor performing routine surgery on a woman noticed that she had cancerous tissue in her womb. He took the initiative to remove the woman's womb; however, as she had not given informed consent for this operation, the doctor was judged by the General Medical Council to have acted negligently. The council stated that the woman should have been informed of her condition, and allowed to make her own decision.

• The doctrine of informed consent also has significant implications for medical trials of new medications.

DASAR INFORMED CONSENT

1. Hubungan dokter-pasien yang berdasar kepercayaan

2. Hak otonomi atau menentukan sendiri atas dirinya sendiri

3. Adanya hubungan perjanjian antara dokter-pasien

TUJUAN INFORMED CONSENT1. Melindungi pasien terhadap segala tindakan medis yang dilakukan tanpa sepengetahuannya. Misalnya prosedur medis yg tdk perlu & tanpa dasar, penyalahgunaan pemakaian alat-alat canggih yg memerlukan biaya tinggi. Di pihak lain, prosedur tsb dpt memberi perlindungan kpd dokter apabila timbul suatu tuntutan. Ia bisa dianggap lalai bila tdk melakukan pemeriksaan tertentu, shg menimbulkan hasil negatif (adverse outcome)

2. Memberikan perlindungan hukum kepada dokter terhadap akibat yg tdk terduga dan bersifat negatif. Misal nya thd “risk of treatment” yg tdk mungkin dihindarkan, walaupun dokter sdh berusaha semaksimal mungkin serta bertindak dg hati-hati dan teliti

3. Melindungi dokter dari Error of Judgement

- Seorang dokter adalah manusia biasa, yg tdk terhindar dari kesalahan dan kekeliruan. Diagnosis yg ditegakkan dan terapi yg diberikan itu bisa keliru, namun dlm batas-batas tertentu (sepanjang dia bekerja secara lege artis), dokter itu tdk dpt dipersalahkan.

- Lain halnya, jika ia melakukan suatu kesalahan besar karena kelalaian (negligence) yg oleh dokter yg lainnya tdk akan dilakukan. Hal tsb dpt terjadi karena unsur ketidaktahuan (ignorance) thd ilmu medis yang terus berkembang pesat, dan sdh menjadi standar medis. Bila itu yg terjadi,maka dia tetap dpt dipersalahkan.

AGAR INFORMED CONSENT MUDAH DIPAHAMI

1. Gunakan bahasa yg jelas & sederhana2. Bila perlu pakai bahasa pasien sehari-hari3. Gunakan kalimat-kalimat yg singkat4. Hindari penggunaan istilah teknis5. Jangan memaksa atau memperkecil risiko6.Jangan membesar-besarkan manfaat7. Jawab semua pertanyaan pasien dengan jujur

TATACARA INFORMED CONSENT1. Informasi hrs diberikan dg itikad baik, jujur, dan tdk bersifat menakut-nakuti, memberi tekanan atau pemaksaan. KUH-Perdata Ps.1321 : “Suatu persetujuan tdk mempunyai nilai hukum jika diberikan karena kekhilafan, diancam dg kekerasan, atau dg tipuan”.

2. Pemberian informasi hrs dilakukan dokter itu sendiri, tdk boleh didelegasikan kpd perawat krn perawat tdk memiliki wewenang, shg bila itu dilakukan, justru membahayakan dokter itu sendiri

3. Informasi hrs diberikan kpd pasien, baik diminta atau tdk diminta, kecuali pasien itu menolak untuk diberi penjelasan. Dlm keadaan itu informasi dpt diberikan kpd keluarga terdekat.

4. Dokter tdk boleh menunda-nunda informasi, kecuali jika dia berpendapat bhw bila informasi itu langsung diberikan kpd pasien, dpt memperburuk keadaannya.

GAWAT DARURAT

PERMENKES No. 585/1989 ps.11: “Seorang pasien yg tdk sadar atau pingsan dan tdk didampingi keluarga terdekat yang secara medis berada dlm keadaan gawat darurat dan perlu tindakan medis segera untuk kepentingannya, tidak diperlukan persetujuan dari siapapun”Bahwa untuk menyelamatkan nyawa atau anggota tubuh pasien (life or limb saving) dan tidak ada waktu lagi untuk menunggu atau menghubungi keluarganya, maka kpd dokter tsb diberi wewenang untuk segera dan secara langsung melakukan tindakan operasinyaBahkan jika tdk diberi pertolongan dan atau tindakan operasi, dokter tsb bisa dituntut berdasarkan kelalaian (negligence) atau penelantaran (abandonment), kalau sampai mengakibatkan meninggalnya pasien tersebut.

Competency

The ability to give informed consent will be governed by a general requirement of competency. In common law jurisdictions, adults are presumed competent to consent. This presumption can be rebutted, for instance, in circumstances of mental illness or other incompetence. This may be prescribed in legislation or based on a common-law standard of inability to understand the nature of the procedure. In cases of incompetent adults, informed consent--from the patients or from their families--is not required. Rather, the medical practitioner must simply act in the patient's best interests in order to avoid negligence liability.

• By contrast, 'minors' (which may be defined differently in different jurisdictions) are generally presumed incompetent to consent. In some jurisdictions (e.g. much of the U.S.), this is a strict standard. In other jurisdictions (e.g. England, Australia, Canada), this presumption may be rebutted through proof that the minor is ‘mature’ (the ‘Gillick standard’). In cases of incompetent minors, informed consent is usually required from the parent (rather than the 'best interests standard') although a parens patriae order may apply (allowing the court to dispense with parental consent in cases of refusal).

Abortion• In some U.S. States, informed consent laws (sometimes

called "Right To Know" laws) require that a woman seeking an elective abortion be given factual information by the abortion provider about her legal rights, alternatives to abortion (such as adoption), available public and private assistance, and medical facts (some of which are disputed - see fetal pain), before the abortion is performed (usually 24 hours in advance of the abortion). Other countries with such laws (e.g. Germany) require that the information giver not be affiliated with the abortion provider, to avoid giving an economic incentive for handing out faulty information.

Sex• The question of whether informed consent needs to be

formally given before sexual intercourse or other sexual activity, and whether this consent can (and must be able to) be withdrawn at any time during the act, is an issue which is currently being discussed in the United States in regard to rape and sexual assault legislation. For example, people who perform sexual acts on sleeping people are not given consent unless the initiator have given prior informed consent to the act within a reasonable recency, and are assumed to be consenting during the act and to not prosecute for it when waking up. This is also an issue in rape fantasy enaction which is often discussed by a "ravishment community" of participants (a subset of the BDSM community) who advocate extensive prior negotiation and planning. The issue of prior informed consent may also come up if the legality behind consensual necrophilia is ever further explored.

• While children may be able to give consent, a more complex question applies in terms of informed consent: whether children are developmentally and otherwise able to give informed consent, in particular to an adult, bearing in mind power relationships, maturity, experience and mental development. For this and other reasons most states have an age of consent under which a child is deemed unable to give consent. As evaluation of maturity, mental maturity, child development, child communication, and child intelligence are further explored, this may be based on psychological and medical evaluation of status for sexual activity instead of chronological age.

• Animals are not usually considered able to give informed consent in a legal sense (although advocates and some ethologists argue they have the capability to agree and strongly solicit such activity), and partly for this reason, but more usually due to concerns for morality and abuse, bestiality is illegal in many jurisdictions. As animal communication methods and evaluation of animal intelligence and animal sexuality changes, this may also change.

No-victim laws• It may not be legally possible to give consent to

certain activities in certain jurisdictions; see the Operation Spanner case for an example of this in the UK which involved sadomasochistic activities such as branding. There are currently several legal challenges underway to address these issues of legality in several nations.

Research

• Informed consent is also important in social research. For example in survey research, people need to give informed consent before they participate in the survey. In medical research the Nuremberg Code has set a base standard since 1947, and most research proposals are reviewed by ethics committees in the 21st century.

REKAM MEDIS(Medical Records)

• Pesatnya perkembangan sains dan teknologi memberi dampak pada hubungan dokter-pasien, yg dulu bersifat paternalistik, kini impersonal (autonomi)

• Pasien tak segan-segan menuntut dokternya karena ada dugaan bhw dokter itu telah berbuat kelalaian

• Permenkes No. 749a/1989 : Pelaksanaan Rekam Medis dengan membuat catatan-catatan sdh merupakan suatu keharusan, sdh menjadi kewajiban hukum

Medical record

• A medical record, health record, or medical chart is a systematic documentation of a patient’s medical history and care. The term 'Medical record' is used both for the physical folder for each individual patient and for the body of information which comprises the total of each patient's health history. Medical records are intensely personal documents and there are many ethical and legal issues surrounding them such as the degree of third-party access and appropriate storage and disposal. Although medical records are traditionally compiled and stored by health care providers, personal health records maintained by individual patients have become more popular in recent years.

MANFAAT REKAM MEDIS

• Rekam medis merupakan hanya satu-satunya catatan yg dpt memberi informasi detil tentang apa yg terjadi dan dilakukan selama pasien dirawat di RS• Rekam medis yg baik memungkinkan dokter & RS merekonstruksi pemberian pelayanan kepada pasien serta memberi gambaran untuk dinilai apakah perawatan dan pengobatan yg diberikan dpt diterima atau tidak dlm situasi saat itu• Rekam medis hrs segera diisi langsung pd saat dilakukan tindakan dan pd pemberian instruksi oleh dokter, atau oleh perawat saat dilakukan observasi, atau tenaga kesehatan lain. Jika hal ini tdk ditaati, bisa terkena tuntutan kelalaian (negligence)

Purpose• The information contained in the medical record allows

health care providers to provide continuity of care to individual patients. The medical record also serves as a basis for planning patient care, documenting communication between the health care provider and any other health professional contributing to the patient's care, assisting in protecting the legal interest of the patient and the health care providers responsible for the patient's care, and documenting the care and services provided to the patient. In addition, the medical record may serve as a document to educate medical students/resident physicians, to provide data for internal hospital auditing and quality assurance, and to provide data for medical research. Personal health records combine many of the above features with portability, thus allowing a patient to share medical records across providers and health care systems.

Format

• Traditionally, medical records have been written on paper and kept in folders. These folders are typically divided into useful sections, with new information added to each section chronologically as the patient experiences new medical issues. Active records are usually housed at the clinical site, but older records (e.g., those of the deceased) are often kept in separate facilities.

• The advent of electronic medical records has not only changed the format of medical records but has increased accessibility of files.

Contents

• Although the specific content of the medical record may vary depending upon specialty and location, it usually contains the patient's identification information, the patient's health history (what the patient tells the health-care providers about his or her past and present health status), and the patient's medical examination findings (what the health-care providers observe when the patient is examined). Other information may include lab test results; medications prescribed; referrals ordered to health-care providers; educational materials provided; and what plans there are for further care, including patient instruction for self-care and return visits. In some places, billing information is considered to be part of the medical record.

Demographics

• Demographics include patient information that is not medical in nature. It is often information to locate the patient, including identifying numbers, addresses, and contact numbers. It may contain information about race and religion as well as workplace and type of occupational information. It may also contain information regarding the patient's health insurance. It is common to also find emergency contacts located in this section of the medical chart.

Medical history

The medical history is a longitudinal record of what has happened to the patient since birth. It chronicles diseases, major and minor illnesses, as well as growth landmarks It gives the clinician a feel for what has happened before to the patient. As a result, it may often give clues to current disease states. It includes several subsets detailed below.

• Surgical history The surgical history is a chronicle of surgery for the

patient. It may have dates of operations, operative reports, and/or the detailed narrative of what the surgeon did.

• Obstetric history The obstetric history lists prior pregnancies and

their outcomes. It also includes any complications of these pregnancies.

• Medications and medical allergies The medical record may contain a summary of the

patient's current and previous medications as well as any medical allergies.

• Family history The family history lists the health status of

immediate family members as well as their causes of death (if known). It may also list diseases common in the family or found only in one sex or the other. It may also include a pedigree chart. It is a valuable asset in predicting some outcomes for the patient.

• Social history The social history is a chronicle of human

interactions. It tells of the relationships of the patient, his/her careers and trainings, schooling and religious training. It is helpful for the physician to know what sorts of community support the patient might expect during a major illness. It may explain the behavior of the patient in relation to illness or loss. It may also give clues as to the cause of an illness (i.e., occupational exposure to asbestos).

• Habits Various habits which impact health, such as

tobacco use, alcohol intake, recreational drug use, exercise, and diet are chronicled, often as part of the social history. This section may also include more intimate details such as sexual habits and sexual preferences

• Immunization history The history of vaccination is included. Any blood

tests proving immunity will also be included in this section.

• Growth chart and developmental history For children and teenagers, charts documenting

growth as it compares to other children of the same age is included, so that health-care providers can follow the child's growth over time. Many diseases and social stresses can affect growth and longitudinal charting and can thus provide a clue to underlying illness. Additionally, a child's behavior (such as timing of talking, walking, etc.) as it compares to other children of the same age is documented within the medical record for much the same reasons as growth.

• Medical encounters Within the medical record, individual medical encounters

are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by a specialist often take an exhaustive form, detailing the entirety of prior health and health care. Routine visits by a provider familiar to the patient, however, may take a shorter form such as the problem-oriented medical record (POMR), which includes a problem list of diagnoses or a "SOAP" method of documentation for each visit. Each encounter will generally contain the aspects below:

• Chief complaint This is the problem that has brought the

patient to see the doctor. Information on the nature and duration of the problem will be explored.

• History of the present illness A detailed exploration of the symptoms the

patient is experiencing that have caused the patient to seek medical attention.

• Physical examination The physical examination is the recording of

observations of the patient. This includes the vital signs and examination of the different organ systems, especially ones that might directly be responsible for the symptoms the patient is experiencing.

• Assessment and plan The assessment is a written summation of what are

the most likely causes of the patient's current set of symptoms. The plan documents the expected course of action to address the symptoms (diagnosis, treatment, etc.).

Orders

• Written orders by medical providers are included in the medical record. These detail the instructions given to other members of the health care team by the primary providers.

Progress notes

• When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc. These often take the form of a SOAP note and are entered by all members of the health-care team (doctors, nurses, dietitians, clinical pharmacists, respiratory therapists, etc). They are kept in chronological order and document the sequence of events leading to the current state of health.

• Test results The results of testing, such as blood tests

(e.g., complete blood count) radiology examinations (e.g., X-rays), pathology (e.g., biopsy results), or specialized testing (e.g., pulmonary function testing) are included. Often, as in the case of X-rays, a written report of the findings is included in lieu of the actual film.

• Other information Many other items are variably kept within the medical

record. Digital images of the patient, flowsheets from operations/intensive care units, informed consent forms, EKG tracings, outputs from medical devices (such as pacemakers), chemotherapy protocols, and numerous other important pieces of information form part of the record depending on the patient and his or her set of illnesses/treatments.

• Administrative issues Medical records are legal documents and

are subject to the laws of the country/state in which they are produced. As such, there is great variability in rule governing production, ownership, accessibility, and destruction.

• Production In the United States, written records must

be marked with the date and time and scribed with indelible pens without use of corrective paper. Errors in the record should be struck out with a single line and initialed by the author. Orders and notes must be signed by the author. Electronic versions require an electronic signature.

• Ownership In the United States, the data contained within

the medical record belongs to the patient, whereas the physical form the data takes belongs to the entity responsible for maintaining the record. Therefore, patients have the right to ensure that the information contained in their record is accurate. Patients can petition their health care provider to remedy factually incorrect information in their records.

• Accessibility In the United States, the most basic rules governing

access to a medical record dictate that only the patient and the health-care providers directly involved in delivering care have the right to view the record. The patient, however, may grant consent for any person or entity to evaluate the record. The full rules regarding access and security for medical records are set forth under the guidelines of the Health Insurance Portability and Accountability Act (HIPAA). The rules become more complicated in special situations.

• Capacity When a patient does not have capacity (is not

legally able) to make decisions regarding his or her own care, a legal guardian is designated (either through next of kin or by action of a court of law if no kin exists). Legal guardians have the ability to access the medical record in order to make medical decisions on the patient’s behalf. Those without capacity include the comatose, minors (unless emancipated), and patients with incapacitating psychiatric illness or intoxication.

• Medical emergency In the event of a medical emergency involving a

non-communicative patient, consent to access medical records is assumed unless written documentation has been previously drafted (such as an advance directive)

• Research, auditing, and evaluation Individuals involved in medical research,

financial or management audits, or program evaluation have access to the medical record. They are not allowed access to any identifying information, however.

• Risk of death or harm Information within the record can be shared with

authorities without permission when failure to do so would result in death or harm, either to the patient or to others. Information cannot be used, however, to initiate or substantiate a charge unless the previous criteria are met (i.e., information from illicit drug testing cannot be used to bring charges of possession against a patient). This rule was established in the United States Supreme Court case Jaffe v. Redmond.

In the United Kingdom the Data Protection Acts and later the Freedom of Information Act 2000 gave patients or their representatives the right to a copy of their record, except where information breaches confidentiality (e.g., information from another family member or where a patient has asked for information not to be disclosed to third parties) or would be harmful to the patient's wellbeing (e.g., some psychiatric assessments). Also, the legislation gives patients the right to check for any errors in their record and insist that amendments be made if required.

Destruction. In general, entities in possession of medical

records are required to maintain those records for a given period. In the United Kingdom, medical records are required for the lifetime of a patient and legally for as long as that complaint action can be brought. Generally in the UK, any recorded information should be kept legally for 7 years, but for medical records additional time must be allowed for any child to reach the age of responsibility (20 years). Medical records are required many years after a patient’s death to investigate illnesses within a community (e.g., industrial or environmental disease or even deaths at the hands of doctors committing murders).

Abuses

• The outsourcing of medical record transcription and storage has the potential to violate patient-physician confidentiality by possibly allowing unaccountable persons access to patient data.

• Falsification of a medical record by a medical professional is a felony in most United States jurisdictions.

• Governments have often refused to disclose medical records of military personnel who have been used as experimental subjects.