Why a shared care record is an official medical record

Area of Science:

• Health Informatics
• Medical Record Management
• Digital Health

Background:

• Health records are categorized into Official Medical Records (OMR), Personal Health Records (PHR), and Shared Care Records (SCR).
• Electronic storage of SCRs introduces complexities, including multi-author contributions and associated record-keeping responsibilities.
• Existing literature requires clarification on the precise definitions and implementations of these record types.

Purpose of the Study:

• To define and differentiate between Official Medical Records, Personal Health Records, and Shared Care Records.
• To explore the challenges and implications of electronic Shared Care Records.
• To examine the legal and ethical standing of Shared Care Records within the broader context of medical record-keeping.

Main Methods:

• Literature review of health record definitions and classifications.
• Analysis of the nature and purpose of Official Medical Records in both paper and electronic formats.
• Case study examination of a New Zealand pilot program for implementing a Shared Care Record within the National Shared Care Planning Programme.

Main Results:

• Shared Care Records are distinct from Personal Health Records, despite patient accessibility and interaction.
• A Shared Care Record functions as an Official Medical Record, not a patient-owned entity.
• The implementation of Shared Care Records necessitates adherence to established medico-legal and ethical duties.

Conclusions:

• Shared Care Records should be classified as Official Medical Records, requiring rigorous standards.
• Patient interaction with Shared Care Records does not equate to patient ownership or control.
• Ensuring medico-legal and ethical compliance is paramount for the successful and responsible implementation of Shared Care Records.