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Keeping joint medical and nursing notes at foot of bed

Editor—Luke et al's report on the views of patients' families and staff on the placing of notes at the foot of the bed shows some advantages of promoting partnerships in health care.1 The authors hint at but unfortunately do not address some difficulties with patients' autonomy, confidentiality, and the content of records, all of which require further consideration. 
 
There are substantial differences between patients and within the same patient at different times in terms of attitudes to patient autonomy.2,3 A blanket policy of making records available to patients without first inquiring about their wishes or explaining the significance of the options listed in a differential diagnosis or test results would be the opposite of a patient centred approach. Staff often misjudge patients' wishes for information and involvement in decisions,2,3 and direct communication between the parties seems the simplest route to reaching agreement. 
 
The question of who else besides the patient might be able to browse through the case notes needs to be considered: should information about termination of pregnancy, psychiatric treatment, or HIV testing be accessible to partners, relatives, and visitors? Patients would need to be fully aware of the contents of their case notes before agreeing to making them potentially available to others. 
 
Patients' access to health records is regulated by the Access to Health Records Act 1990, and refusal to disclose information is possible if the health professional is satisfied that serious physical and mental harm can occur. Whether entries in the case notes and correspondence from third parties should be automatically accessible to patients without the consent of the author of the communication is questionable. As a general hospital psychiatrist, I routinely write in the case notes of patients seen for consultation and correspond with doctors who have referred them; I would wish to be asked before my assessment and management advice were made available to patients. Alternatively, case notes could be screened and third party or potentially harmful communications removed, but this would lead to two sets of records (confidential and super-confidential?), which would defeat the object of the exercise. 
 
New technologies in the form of electronic records and PINs (personal identification numbers) allowing patients access to health records may well provide answers to some of these difficulties and new challenges. They will not, however, do away with the need for healthcare workers to communicate directly with their patients to find out how much they already know or wish to learn about their health, to keep them involved in decisions about treatment, and to ensure that a true partnership develops.