Health Information: Andy’s Case
Andy Hanson’s case raises some critical questions on the level of detail of a patient’s sexual history doctors’ should document. The case also highlights the issue of paraphrasing recorded verbatim in medical records. Doctors Lee and Weiss documented Andy’s sexual history comprehensively, which made it possible for them to conduct tests and diagnose HIV. As such, the level of information that the two doctors collected was appropriate and necessary for Andy’s workup of care.
The doctors violated no standards because collecting a thorough sexual history of adolescents is vital, provided the information is obtained in a nonjudgmental and ethical manner. Furthermore, since Andy confessed to being a gay male and having multiple sexual partners, a detailed sexual history was deemed necessary because he is at a higher risk of contracting sexually transmitted diseases. Therefore, no standards were violated because collecting sexual risk history is a vital part of the medical interview that allows practitioners to gauge a patient’s risk for HIV infection.
Information on Andy’s sexual orientation, sexual partners, and the diagnosis should be restricted and only accessed by his physicians. According to the stipulated ethical codes and legal regulations, Andy’s medical records should only be accessed by the practitioners assigned to his case. Andy’s medical records should not be accessed by his parents, relatives, or any other individuals who are not concerned in providing him with clinical and psychiatric care.
Guidelines from statutes such as HIPAA can be used as controls to ensure all clinicians comply with regulations and ethical codes on the management patients’ records. Hospitals can also enforce policies by institutions such as the American Health Information Management Association to ensure that doctors adhere to standards on collecting and documenting patient information.