I remember there was a time when there weren't sign-in sheets in any type of doctors' offices. It was when the receptionist knew all the patients by name and sat at a desk that was in the waiting room. Then something happened. It was a business decision. The reception desk moved behind the opaque sliding glass door, so patients wouldn't interrupt office work. This created a psychological barrier between the doctor/staff and patients. The sign-in sheet was needed so that the staff, when they popped their head out from the glass door like the watchman in the Emerald City of Oz, could peer down at the list and see who had arrived, since they did not have any personal knowledge of patient identities.
The coldness described is not typical of chiropractic practices. So, doctor, why do you have a sign-in sheet? "To document which patients came into the office," is the answer. The problem is that having each patient sign the sheet means that patients signing-in can see the names of patients already seen that day. The first rules proposed under the Health Insurance Portability and Accountability Act (HIPAA) would have made sign-in sheets illegal. However, in August, the Department of Health and Human Services revamped the rules to allow for the "incidental" disclosure of private information that sign-in sheets cause. Even prior to HIPAA, it had been suggested by some that sign-in sheets are an illegal invasion of privacy. Nonetheless, the question I pose is, regardless of the legality of sign-in sheets, are they ethical?
We all know that revealing patient information is unethical. The chiropractic oath enlightens us of this with the statement: "I will keep inviolate all things revealed to me as a physician." But isn't the mere fact that someone is a patient a bit of confidential information? I submit that it is.
Here is a hypothetical situation. Say a patient, we'll call Worker, is applying for a job. Big, Worker's potential boss, goes to his chiropractic appointment and sees Worker's name on the sign-in sheet. Big assumes Worker is probably seeing the chiropractor for back pain. He knows the company has recently been hit with a few expensive workers'compensation claims, and decides that Worker poses a risk for a work-related injury. Worker is no longer under consideration to be hired.
Was this right? No, of course not. Big has made a hiring decision biased on a sign-in sheet.
So much personal health information has been reported in the media that we have become desensitized to the confidential nature of the doctor/patient relationship. Not everyone has forgotten about confidentiality. Not long ago, when Michael Jackson disappeared from the public eye, there were rumors that he was in a drug rehab facility here in Connecticut. The local news played a tape of a phone call to the facility. The reporter asked if Jackson was a patient. The receptionist immediately transferred the call to a recorded message that said, "We will neither confirm nor deny the status of any person as a patient at our facility."
It is the patient who decides what information is confidential. It is incumbent upon us not to force the patient into proactively asking for their information, including the establishment of a doctor-patient relationship, to remain confidential. We need to ask permission to divulge any bit of information (including that they referred us patients, their birthdays, etc.). They should not have to request a special dispensation so that they do not have to sign in. We should establish office policies that protect their privacy. Two alternatives for documenting the patient's presence are specially designed confidential sign-in sheets (the earlier proposed HIPAA rule has stimulated a few companies into developing the special sign-in sheets), or having patients sign their daily chart notes.
Finally, violating codes of conduct may have serious business repercussions. People may leave a practice and tell all their friends that an ethical breach is why they left. Thus, an ethical breach may be legal, but it can destroy the goodwill that the doctor has worked hard to build in the community. Doctor-patient confidentiality is not just maintaining the privacy of the patient's health records - it is also maintaining the privacy of the mere fact that someone is your patient.
Stephen Perle,DC,MS,CCSP
Associate Professor of Clinical Sciences
University of Bridgeport College of Chiropractic
Bridgeport,Connecticut
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