Research results and medical records

Can research data/results be included in a patient’s medical record?

Data/results that are generated through research may be included in a patient medical record when:

1. the research data/results are generated through a validated method, AND
2. clinical use of the data/results are supported by a published practice/clinical guideline, AND
3. including the research data/results in a patient’s medical record is supported by the patient’s written informed consent.

It is the responsibility of the PI to follow institutional process in adding the documents to the patient chart.

Note: The research and clinical landscape changes over time as more is learned so the decision to report should be based on current evidence and can not be expected to change beyond the duration of the study. The care plan ultimately rests with the clinician and their patient.