Full Access to Doctor's Notes

In de Annals of Internal Medicine is een artikel verschenen over een onderzoek naar een volledig toegankelijk medisch dossier, de zogenaamde "Open Notes".

Figure. Access to doctors' notes.

QA = quality assurance.

De auteurs noemen als potentiële voor- en nadelen:

Potential advantages

-Improved patient understanding of his or her medical condition

-Additional patient insight into medical decision making

-Increased patient participation in care

-Improved patient adherence to treatment plan (e.g., medications and self-care)

-More timely completion of notes

-Contribution to accuracy and completeness of the record

-More eyes on documentation, possibly avoiding medical errors

-Reinforcement of patient memory (e.g., about the treatment plan)

-Better patient preparation for visits, making visits more effective and efficient

-Greater patient trust and appreciation of a clinician’s work

-Facilitation of the patient sharing notes with others

Potential disadvantages

-Perceived pressure for patients to read notes

-Patient confusion or misunderstanding of medical terminology

-Concerns about breaches of privacy and security (e.g., to employers or government agencies)

-Increased patient anxiety or sense of psychological exposure for mental health issues

-Patients taking offense to descriptions of the patient, encounter, or both

-Distortion of the clinical encounter by focusing too much on the note

-Need for additional clinician time after the visit to address patient

-concerns about the note

-Unwelcome changes in documentation (e.g., more time to create a patient-appropriate note and less candor about observations or clinical reasoning)

-Exposure of suboptimal notes, clinician worries about negligence, and malpractice

Lees het hele artikel: fulltext / pdf.