What should not be included in a patient's medical record without specific authorization?

In the context of patient records, non-clinical personal assessments refer to subjective evaluations or opinions that are not directly related to healthcare or treatment, such as personal opinions on lifestyle or social circumstances without the patient's expressed consent. Including such information in a patient's medical record without specific authorization raises ethical concerns regarding patient confidentiality and consent.

Patient medical records are primarily intended to document clinical information related to diagnosis, treatment, and outcomes. Sensitive information, especially that which is not clinically relevant, must be handled with care. Therefore, the inclusion of non-clinical assessments lacks the necessary relevance to medical care and can infringe on patient privacy rights. Specific authorization is needed to include such opinions to ensure that patients' rights are respected and their information is only shared with appropriate stakeholders.

The other elements listed—diagnosis and treatment history, user identity and insurance details, and medications administered—are integral components of the medical record with direct relevance to the patient's care and treatment, and generally do not require separate authorization to be included in the record as they facilitate proper medical care and billing processes.