von Schönfeld Carl-Ernst, Roos-Pfeiffer Wolfgang, Driessen Martin
Tagesklinik Bethel, Zentrum für Psychiatrie und Psychotherapeutische Medizin, Bielefeld.
Psychiatr Prax. 2003 Mar;30(2):56-61. doi: 10.1055/s-2003-37444.
We present the concept of an extended documentation of psychiatric-psychotherapeutic treatment with the patients being in the center of information. Apart from a short treatment report for the outpatient therapist, we write a detailed letter to the patients themselves including informations and backgrounds of their psychiatric and medical history, psychopathological findings, diagnose(s), course of the current treatment and recommendations for the future. This procedure is in agreement with the tradition of psycho-educative approaches and self-management concepts. It intends to support patients to be self-conscious and responsible partners during and after the treatment process. We performed a pilot study for a predominantly descriptive evaluation of the concept in the day clinic setting. A standardized questionnaire in 30 previously treated patients and three case studies yielded a high acceptance and positive appraisal of the received letters with a substantial subjective impact for coping with the disorder and a positive option for dealing with family members and friends.
我们提出了以患者为信息核心的精神心理治疗扩展记录的概念。除了为门诊治疗师撰写一份简短的治疗报告外，我们还会给患者本人写一封详细的信，内容包括他们的精神病史和病史信息及背景、精神病理学检查结果、诊断、当前治疗过程以及对未来的建议。这一程序符合心理教育方法和自我管理理念的传统。其目的是支持患者在治疗过程中和治疗后成为有自我意识和负责任的伙伴。我们在日间诊所环境中进行了一项初步研究，以对该概念进行主要是描述性的评估。对30名既往接受治疗的患者进行的标准化问卷调查以及三个案例研究表明，患者对收到的信件接受度很高且评价积极，对应对疾病有很大的主观影响，并且在与家人和朋友相处方面有积极的选择。
