Golodetz A, Ruess J, Milhous R L
Arch Phys Med Rehabil. 1976 Feb;57(2):78-81.
Each patient admitted to the 16-bed Rehabilitation Medicine Service at Medical Center Hospital of Vermont since October 1972 has received a carbon copy of his full Admission and Discharge notes, containing the complete problem list, and for each problem the relevant data, the Assessment and the Plans. The objectives were to improve patient education; to improve the patient's chances to contribute to the planning of his care; and to increase the staff's accountability to the patient. Over a period of seven months, we evaluated the effect of this maneuver for 125 consecutive patients by means of (1) a report on the patient's reactions, completed by a nurse after she reviewed the record with the patient; (2) a report by the physician stating whether he had expurgated the record for patient use, and recording his observations of patient and family reaction; (3) a questionnaire mailed to patients after discharge. Results indicated that patients were generally comfortable about reading the record, found it educational and appreciated the trust implied. No substantial difficulties arose. Few records were expurgated. The staff has accepted this style as crucial to an appropriate sharing of responsibility between themselves and the patients. We conclude that giving the patient his record is a safe and inexpensive aid to the rehabilitation process, and is probably mandated by the changing relationships between professionals and their clients, and by the patient's need to negotiate his own health care in an increasingly complex and mobile society.
自1972年10月以来，入住佛蒙特医学中心医院拥有16张床位的康复医学科的每位患者都收到了一份其完整的入院和出院记录的副本，其中包含完整的问题清单，以及针对每个问题的相关数据、评估和计划。目的是改善患者教育；增加患者参与其护理计划的机会；并提高工作人员对患者的责任感。在七个月的时间里，我们通过以下方式对连续125名患者进行了此项举措的效果评估：（1）一份关于患者反应的报告，由护士在与患者一起查看记录后完成；（2）医生的一份报告，说明他是否对供患者使用的记录进行了删改，并记录他对患者及家属反应的观察；（3）出院后邮寄给患者的一份问卷。结果表明，患者通常对阅读记录感到安心，认为它具有教育意义，并感激其中隐含的信任。未出现重大困难。很少有记录被删改。工作人员已将这种方式视为他们与患者之间适当分担责任的关键。我们得出结论，将记录交给患者对康复过程来说是一种安全且低成本的辅助手段，这可能是由专业人员与其客户之间不断变化的关系，以及患者在日益复杂和流动的社会中自行协商医疗保健的需求所决定的。
