Behavior: Ask the experts




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Q A 14-year-old girl who came to my office with her mother complaining of a sore throat told me privately that she had performed oral sex on a boy. She was frightened about having contracted a sexually transmitted disease. I ordered pharyngeal cultures for gonorrhea and Chlamydia and talked to her about returning for HIV testing. After the testing, the girl confided in her mother.

Upon learning that all results were negative, mother and daughter asked me to remove the culture results and notes from the teen's chart to protect her reputation and keep her sexual history private. The girl is especially worried that her father will find out what happened. How should I respond? Is it legal to change the record in this way?

Marc Wager, MD
New Rochelle, N.Y.

A Your question raises legal, ethical, and clinical issues. Legally, the medical record is governed by state law regarding an adolescent's right to medical care and, specifically, to care of a sexually transmitted disease. In addition to state law, insurance regulations and third-party reimbursement contracts may govern amendments to the medical record.

In general, the medical record is considered a legal document that can be changed only by crossing out information that is in error and entering a note that clarifies the change. As a practical matter, these laws, regulations, and rules are applied much more stringently to hospital inpatient and outpatient records than to the records of a practitioner in group or private practice. Furthermore, your likelihood of being prosecuted if you decided to delete clinical information related to this patient's care is extremely small.

An alternative to the either-or solution of having no record or a complete record is to create a confidential shadow file, with the adolescent patient's consent, that is accessible only to you. It may be reasonable office practice to inform parents routinely of a confidential shadow record system when a patient turns 12 or 13 years old, given the likelihood that similar problems will arise again.

As to whether it is ethical to remove notes from the teen's chart, your burden is lightened by the fact that your patient confided in her mother; you would not be acting in complete absence of parental consent. The patient and her mother are specifically asking you to break a customary procedure and social contract—and a legal responsibility. This places your obligation to maintain an accurate record in direct conflict with your obligation to serve the patient.

If the information omitted from the medical record had an impact beyond the patient's personal life—such as seizure disorder, which would make her ineligible for a driver's license—I would weigh the social obligation above her right of confidentiality. Another example would be diabetes; in such a situation, silence in the medical record could delay critical medical care. In the case you describe, I would weigh the patient's rights more heavily than the social contract and respect her request, assuming all test results are negative on follow-up.

The clinical questions are more complex, however. Why did she engage in this sexual activity? Are other risk factors jeopardizing her well-being, such as substance use, depression, academic difficulties, a self-image that puts her at risk of being used by others, or sexual abuse? What are the likely aftereffects of this experience for her? Guilt? Traumatic memories? A lower threshold for sexual activity?

Last, what are the consequences of a secret in the family, between her and her father and between her parents? These questions need to be addressed in the context of a trusting clinical relationship and are likely more central to her future than any decision about the medical record.

Michael S. Jellinek, MD
Boston, Mass.

DR. JELLINEK is Senior Vice President for Administration and Chief, Child Psychiatry Service, Massachusetts General Hospital, and Professor of Psychiatry and of Pediatrics, Harvard Medical School, Boston.


Q The experienced teacher in my child's kindergarten class (5- to 6-year-olds) is feeling desperate about the behavior of the youngsters under her care. She is teaching an all-day kindergarten for the first time. The class has 16 children (11 boys and five girls), and the teacher has an aide. The children do not have any specific impairments or special needs, though some children are "at risk." Every day after lunch, from about 1 to 2 p.m., the children are on widely separated mats and are supposed to be quietly "reading" or looking at books. Instead, they often are out of control, and the adults are exhausted by the time they get them to pay attention. The teacher wonders if such behavior is normal at this age. If so, how can she address the children's "hyperactivity" so the afternoon is not wasted?

Jerri Jenista, MD
Ann Arbor, Mich.

A The mantra that I often use with parents of toddlers and preschoolers who have questions about their child's sleep is that "adults want to fall asleep; children want to stay awake." Remembering this basic fact is often helpful in reframing the difficulty individuals may be having around either sleep or "quiet time." It often is very difficult for children who are thoroughly enjoying their day to "separate" from it, even briefly.

Between 4 and 7 years of age, the sleep needs of children may decrease to 10 1/2 to 11 1/2 hours every 24 hours, and they may or may not need a nap. Thus, children in your child's kindergarten class may fall anywhere within this range. Likewise, children's temperaments will run the gamut in a class of 16. They may vary greatly in levels of activity, persistence, regularity, and distractibility, all of which can influence how they a approach a regularly scheduled quiet period.

It is good that quiet period is after lunch. The teacher may also want to restructure the day so that quiet period is immediately after a circle time where the children are brought together to listen to one or two books that are read to them as a group. They may also sing a quiet song as they each get their mats to begin quiet time. For a particularly challenging class or one in which many children have high activity levels, doing relaxation exercises with the entire group may be useful. These exercises can range from simple deep breathing to more sophisticated "script exercises," like those described in Ready, Set, Relax: A Research-Based Program of Relaxation, Learning, and Self-Esteem for Children by Jeffrey S. Allen and Roger J. Klein and Cool Cats, Calm Kids: Relaxation and Stress Management for Young People by Mary L. Williams.

Another clever idea is for the teacher to make up special "nap bags" for the children to choose each day. Each bag contains one or two special books and some crayons or small objects to manipulate that the child can play with without distracting his or her peers. The children can choose a different "nap bag" each day to keep their interest.

Marilyn Augustyn, MD
Boston, Mass.

DR. AUGUSTYN is Assistant Professor and Director of Training, Division of Developmental and Behavioral Pediatrics, Boston Medical Center.


Morris Green. Behavior: Ask the experts. Contemporary Pediatrics 2001;4:33.

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