Censoring of patient-held records by doctors

Abstract

Computer-held information is increasingly shared between general practice and hospitals and with the provisions of the Data Protection Act now in operation, the practical issues of disclosure to patients need to be reviewed. Patients attending diabetic clinics at University Hospital, Nottingham, are routinely issued with a copy of their computerheld record but a previous study showed a high level of censoring by the hospital doctors. This paper reports a review of a sample of 251 censored records, containing 426 problems, whereby the doctors concerned provided reasons for the censoring and restored information they thought suitable. After the review, only 8% of censored problems, that is 1% of all problems, remained censored. An additional 2% of all problems were deleted from the patient's copy at the request of the patient. It is essential that systems which allow censoring of patient records have continuous built-in audit to monitor the reasons for censoring.