Indonesian Doctors Competence

Standard
(Konsil Kedokteran Indonesia, 2007)

Competency areas:
1.
2.
3.
4.
5.
6.
7.

Effective communication
Clinical Skill
Scientific based medical sciences
Health problem management
Information management
Self evaluation and development
Ethics, Moral, Medicolegal,
Proffesionalism and Patients safety

Informed consent
Informed 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
patients 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.

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)

Suatu tindakan medis tidak

bertentangan dg hukum, bila:
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 )

INFORMED CONSENT/CHOICE
Persetujuan 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 diintimidasi
Dibuat 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-ageappropriate 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 CONSENT

1. 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 & sederhana
2. Bila perlu pakai bahasa pasien sehari-hari
3. Gunakan kalimat-kalimat yg singkat
4. Hindari penggunaan istilah teknis
5. Jangan memaksa atau memperkecil risiko
6.Jangan membesar-besarkan manfaat
7. Jawab semua pertanyaan pasien dengan
jujur

TATACARA INFORMED CONSENT

1. 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 operasinya
Bahkan 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 patients 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 healthcare 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 patients 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 patients 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 patientphysician 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.