You do not need to get ethics approval to access a patient chart and publish a case report.

Ensure patient privacy

From an ethics standpoint, case reports are not considered ‘research’ even though they are published in research journals. Case reports – like case studies, etc - are educational contributions. You do not need to get ethics approval to access a patient chart and publish a case report. However, patient privacy is crucial.

 
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Where possible you should get patient consent using the 

If the patient case is very unique, then you must get patient consent.


In most cases you will need to access a chart from a patient case from the past. In this situation, the case must be sufficiently anonymized such that the details of the case cannot be associated with any particular individual.

 

You must complete the Patient Privacy Declaration Form and take steps to anonymize the case.
 

You must omit or modify any non-relevant detail, for example:

  • Never disclose the patient's name

  • Never give irrelevant encounter details, such as name of the clinical site, staff names, unique site details, date of encounter, month of encounter, etc

  • Personal patient details such as gender, age, martial status, family details, ethnicity, etc

  • Clinical details such as irrelevant co-morbidities, unique details, etc

For Undergraduate Learners: How to access patient charts

In most cases, you will need to review a patient chart to recall details that you will need to describe the case. Also, you will need the details in order to sufficiently anonymize/modify non-relevant details that can identify the patient.

Follow these steps and instructions:

  • You may only access patient chart with the consent of your preceptor and/or the attending/supervising clinician.

  • You must access the patient chart with the direct supervision of your preceptor and/or the attending/supervising clinician.

  • The preceptor and/or the attending/supervising clinician should be a coauthor on the case report or acknowledged.

  • You must follow all relevant privacy guidelines from the institution you are collecting the case from.

In most cases, your preceptor and/or the attending/supervising clinician will have easy access to the electronic and patient chart. In some cases, she or he will have to request it from the records department on your behalf. Follow the institution's guidelines.

Note: If you – through your preceptor - are trying to access a chart from Grand River Hospital and the patient is already discharged, then you must to complete a “Request To Review Personal Health Information Form” and follow the policy.