Nunes José Pedro L, Faria Maria do Sameiro, Abreu Amorim Carlos
Faculdade de Medicina da Universidade do Porto.
Centro Materno Infantil do Norte, Porto.
Porto Biomed J. 2020 Mar 26;5(2):e62. doi: 10.1097/j.pbj.0000000000000061. eCollection 2020 Mar-Apr.
The family history is a traditional section of the clinical record. Data on family members in the clinical record may be anonymous but yet these may be easily identifiable; therefore, exposing the relatives of the patient to the fact that a written record is produced, mentioning them, without their consent. This is in direct contradiction with European data protection and other regulations and in contradiction with a reasonable ethical perspective. For the purpose of obtaining an image of the present state of affairs, we used as a convenience sample, the series of Case Records published in 2019 in (January to December). From a total number of 40 reports, identifiable relatives were present in 30. The number of identifiable relatives varied between none and 6. It is not the right of each individual to disclose sensitive clinical information regarding other persons, without consent from these latter. Family history should no longer include identifiable relatives, unless consent is obtained from each identifiable person. The authors offer the following guidelines on this topic: (1) Do not mention any identifiable relative of the patient in the medical history without consent from the said relative; (2) Do not mention in the family history clinical conditions seemingly unrelated to the present clinical situation; (3) Do not mention in the family history clinical conditions that the patient does not (him/) herself have and that may be seen as social stigmata; (4) Consult the institutional Ethics committee in case of reasonable doubt.
家族史是临床记录的一个传统部分。临床记录中关于家庭成员的数据可能是匿名的,但仍可能很容易被识别;因此,在未经患者亲属同意的情况下,让他们知晓有一份书面记录提及了他们。这与欧洲数据保护及其他法规直接相悖,也与合理的伦理观念相矛盾。为了了解当前的情况,我们以2019年全年(1月至12月)发表的一系列病例记录作为便利样本。在总共40份报告中,有30份存在可识别的亲属信息。可识别亲属的数量在0至6人之间不等。未经他人同意就披露关于其他人的敏感临床信息,这并非每个人的权利。家族史不应再包含可识别的亲属信息,除非获得每个可识别人员的同意。作者就该主题提供了以下指导原则:(1)未经所述亲属同意,在病史中不得提及患者的任何可识别亲属;(2)在家族史中不得提及与当前临床情况看似无关的临床病症;(3)在家族史中不得提及患者自身没有且可能被视为社会耻辱的临床病症;(4)如有合理疑问,咨询机构伦理委员会。