Who has access to your medical charts?

[gogogo]

I’m working in a community clinic and I’m concerned by how the attending runs it. Specifically, she has her secretary (who has no degree in any healthcare field) read and edit all of the dictations in patients’ charts. In other words, the secretary is reading through the patients personal medical information. Is it just me, or is this problematic?

[InstantRamen]

.

[JohnGrisham]

1 hour ago, gogogo said:

I’m working in a community clinic and I’m concerned by how the attending runs it. Specifically, she has her secretary (who has no degree in any healthcare field) read and edit all of the dictations in patients’ charts. In other words, the secretary is reading through the patients personal medical information. Is it just me, or is this problematic?

It is definitely problematic, but suppose one could argue they are apart of the circle of care - and if the secretary did something negative, that it would be the attendings license on the line.

Realistically MOAs will see most of the incoming faxes/consult reports/labs etc anyways, so taking it one step further to edit for grammar etc perhaps isn't a huge divergence from what they already have access to?

I'm not condoning it, and i wouldn't personally ever have someone who isn't at least a nurse editing my dictations, but it is relatively common for MOAs to finalize dictations and "pretty them up" in some specialty practices.

[frenchpress]

2 hours ago, gogogo said:

I’m working in a community clinic and I’m concerned by how the attending runs it. Specifically, she has her secretary (who has no degree in any healthcare field) read and edit all of the dictations in patients’ charts. In other words, the secretary is reading through the patients personal medical information. Is it just me, or is this problematic?

I don’t think it’s inherently problematic. Our data heavy healthcare system can’t function without a lot of middle men. Going digital hasn’t really changed this. On the whole there’s a lot more IT people and fewer secretaries typing dictations these days, but the practice is still wide spread. It also has its benefits - someone who is well trained will often catch mistakes. And It’s not really any different from how things are set up in hospitals. Many people working in administrative and support positions in hospitals that handle data do not have degrees in health care. When you dictate into a phone at the hospital, there’s often a transcriptionist on the other end. You don’t need a health care related degree to be trained to competently work with many kinds of health related data, just like you don’t need a health degree to go into medical school!
 

What matters is the training and privacy standards associated with the job. Just like with IT people and care aids and unit clerks and medical staff etc etc in the hospital who have to sign non-disclosure agreements and receive training about privacy etc. when working with hospital data systems, if you have staff in your office handling patient data then they should receive proper training, be asked to sign agreements about their obligations for data privacy, etc. If you’re not doing those things, then yes, potentially problematic.

[bearded frog]

5 hours ago, gogogo said:

I’m working in a community clinic and I’m concerned by how the attending runs it. Specifically, she has her secretary (who has no degree in any healthcare field) read and edit all of the dictations in patients’ charts. In other words, the secretary is reading through the patients personal medical information. Is it just me, or is this problematic?

That's completely normal and not at all problematic. Although real-time dictation is more common a lot of staff have their assistants dictate their letters and make calls on their behalf. They are responsible for confidentiality just as much as the doc.