Recupero Patricia R
The Warren Alpert Medical School of Brown University, and Butler Hospital, 345 Blackstone Boulevard, Providence, RI 02906, USA.
Child Adolesc Psychiatr Clin N Am. 2008 Jan;17(1):37-51, viii. doi: 10.1016/j.chc.2007.07.004.
In child and adolescent psychiatry, medical records and professional communications raise important ethical concerns for the treating or consulting clinician. Although a distinction may be drawn between internal records (eg, medical records and psychotherapy notes) and external communications (eg, consultation reports and correspondence with pediatricians), several ethical principles apply to both types of documentation; however, specific considerations may vary, depending upon the context in which the records or communications were produced. Special care is due with regard to thoroughness and honesty, collaboration and cooperation, autonomy and dignity of the patient, confidentiality of the patient and family members, maintaining objectivity and neutrality, electronic communications media, and professional activities (eg, political advocacy). This article reviews relevant ethical concerns for child and adolescent psychiatrists with respect to medical records and professional communications, drawing heavily from forensic and legal sources, and offers additional recommendations for further reading for clarification and direction on ethical dilemmas.
在儿童和青少年精神病学领域，病历记录和专业沟通给主治或会诊临床医生带来了重要的伦理问题。虽然内部记录（如病历和心理治疗记录）与外部沟通（如会诊报告以及与儿科医生的通信）之间可能存在区别，但有几条伦理原则适用于这两类文档记录；然而，具体考量可能因记录或沟通产生的背景而异。在全面性与诚实性、协作与合作、患者的自主性与尊严、患者及其家庭成员的保密性、保持客观性与中立性、电子通信媒介以及专业活动（如政治倡导）等方面，都需要格外谨慎。本文回顾了儿童和青少年精神科医生在病历记录和专业沟通方面的相关伦理问题，大量借鉴了法医和法律方面的资料，并提供了更多推荐读物，以阐明伦理困境并给予指导。
