Medico-legal Correspondence - Where to Store it?

Case history

Dr A took a history and found that she had not seen a doctor for some years. She had no significant past history and was not taking any medication. He performed a thorough examination, which was unremarkable and then ordered some pathology testing to further investigate her feeling of tiredness.

Four days later Mrs Brown returned to review her results with Dr A. Her TSH was quite elevated 18 mU/L(normal range .53.5mU/L).

Dr A explained to Mrs Brown that her thyroid was not working properly, that she would need to have some further blood tests, should start taking thyroxine and would probably need to take it for life. Mrs Brown was very unhappy at this news. She agreed to further blood tests, but said she would consult with her naturopath.

Further tests showed a raised antithyroid peroxidase 228IU/L (normal range <6¹). Mrs Brown returned to Dr A and told him that her naturopath was treating her with some natural tonics and supplements and she was feeling better already. Mrs Brown was adamant that no medication was necessary, but she agreed to return for follow up blood tests. Over the next 6 months, Mrs Brown had blood tests on several occasions and her TSH was between 15-20 mU/L each time. Dr A repeated his advice but Mrs Brown remained unconvinced of the need for medication.

In October 2007, Mrs Brown presented stating she was feeling ‘terrible’, very sluggish and unable to cope with her children. In the interim months she had had some contact with the local mental health services and been diagnosed with depression. She was receiving counselling but was not taking any medication. Further testing showed her TSH was now 99 mU/L and her T4 <5 pmol/L (normal range 9-19). Dr A recommended again that she commence thyroxine and Mrs Brown reluctantly agreed to commence 50mcg daily.

A few days later Mr and Mrs Brown were in to see Dr A again. Mrs Brown was feeling worse than ever, in fact she stated that she felt so dreadful that she wanted to die. Because she had been feeling so bad, she had taken 5 tablets a day of the thyroxine, felt it had only made her worse and did not think she would continue with it. Dr A was not sure whether her current state was due to depression or hypothyroidism and he suggested that she present to the local hospital or be referred to an endocrinologist.

Dr A was very concerned with Mrs Brown’s condition and refusal to take thyroxine. He phoned MDA National and discussed the situation at length with them. Dr A then typed in the patient’s computerized progress notes ‘spoke to MDO, they think this is a serious case and I should be sure to document all phone calls and consultations very carefully’.

Dr A typed into the patient notes ‘further conversation with MDO,they will open a file and please send a copy of patient’s records to MDO’.

Some months later, Dr A received a request from Mrs Brown for a copy of her medical file, as she wanted to transfer to another doctor. When Dr A reviewed Mrs Brown’s file, he realised that the comments about him consulting MDA National were included in the file. He felt very uncomfortable about that and he asked for further advice. Dr A had also made some less than complimentary comments about the husband including describing him as ‘obstructive’, ‘ill-informed’ and ‘difficult’. 

Under the Privacy Act, National Privacy Principle 6², a healthservice provider is obliged to give an individual access to their personal information. Access can be denied in certain circumstances, one of which is if access would pose a serious threat to the life or health of the individual and this threat must be judged to be significant. Dr A did not feel that access would pose a serious threat to the patient’s health, so it could notbe denied on this basis. However, access can be provided ina number of ways and a summary can be provided if that is acceptable to the patient.

In this case, the practice then wrote back to Mrs Brown, explaining that her notes were extensive and that it would be more helpful to her next doctor to have a summary of her records. Mrs Brown agreed to this.