All of the scenarios in the garrison healthcare suit should be considered from the perspective of a healthcare professional working in a military garrison healthcare centre with responsibility for the clinical care of patients and management of the healthcare centre. The primary supporting reference for this suit is the World Medical Association International Code of Medical Ethics (WMA Code) at: https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/ . You should also consider your national professional ethical codes and relevant military law or guidance

Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario: You are reviewing the electronic health record of a young soldier whom you think is being bullied. You notice that one of your colleagues has seen him and seems to have deleted some notes. What do you do?
• List the Issues that arise from the scenario.
• Identify Critical Information required and Assumptions to be made:

This scenario covers the ethics and law regarding record-keeping, access to medical records, and the responsibility to report/investigate unethical/illegal behaviour by colleagues.  

Step 2 – ANALYSE

Patient: your patient has the right to expect that their medical records are appropriately managed, without unauthorised access or changes. The patient also has a right to know that such changes have been made.

Clinical: you have a responsibility to ensure that the personnel in your clinic understand their rights and duties regarding the sanctity of health records. WMA Code 21. The physician must ensure accurate and timely medical documentation.

Legal: It is highly likely that there are policies and rules regarding access to medical records and authority to change them. It is likely to be forbidden to delete any information without any oversight.

Societal/Military: In addition to the likely fact that your colleague has failed in their duties in regard to the patient’s medical records, there will also be the question of why? Is there a link to the concern over bullying.

Step 3 – FUSE

• Summarise conclusions
• Insert citations to key reference sources for your analysis
• Determine the exact Decision(s) to be made

The possibility of unauthorised changes to the patient’s medical record needs to be investigated and the reasons why understood. Electronic medical records should provide ‘stamps’ showing the time/date/person for all access and changes. 

Step 4 – DECIDE

• What is your Decision?
• Why (can you justify it)?
• Residual uncertainly, need for review?

You will need to investigate the reason for the missing notes. How you raise this will depend on your role/rank/relationship with your colleague. This investigation may result in disciplinary action, and so should follow appropriate procedures. The patient will need to be informed of both the changes to their record and the subsequent actions.  You may wish to seek confidential advice from your professional body.

Contributors – Brigadier (Rtd) Charles Beardmore MBBS MRCGP MFOM MA MSc MBA LLM. Charlie is a qualified General Practitioner with 32 years of military service that culminated in the role of Head of Defence Primary Healthcare in the UK. He is studying for a PhD on the topics of military healthcare ethics. Brigadier Phil Carter MBChB MRCGP MPH MA. Phil is a qualified General Practitioner with 28 years of military service, He recently served as Commander of Defence Primary Healthcare in the UK and Chief Medical of a multinational operational headquarters in the Middle East.