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非专业人士阅读病历的体验。

Lay people's experiences with reading their medical record.

机构信息

Oslo University Hospital, Center for Shared Decision Making and Nursing Research, Oslo, Norway.

出版信息

Soc Sci Med. 2011 May;72(9):1570-3. doi: 10.1016/j.socscimed.2011.03.006. Epub 2011 Mar 24.

Abstract

An increasing number of patients now make use of their legal right to read their medical record. We report findings from a study in which we conducted qualitative interviews with 17 Norwegian adult patients about their experiences of requesting a copy of their medical record following a hospital stay. Interviews took place between May, 2008 and April 2009. The analytical process, guided by qualitative content analysis, identified two main themes; "keeping a sense of control" and "not feeling respected as a person". The informants' experiences with reading their own medical record were often connected to their experiences in direct communication with health care professionals during the hospital stay, revealing a delicate interaction between trust and power. The informants were hoping for a more mutual exchange of information and knowledge from which they could benefit in the management of their own health. We conclude that to meet patients' expectations of mutuality, health care professionals in hospitals need to be more conscious about their attitudes and communication skills as well as how they exercise their power to define the patient's situation. At the same time, there should be more focus on how structural changes in the organization of hospitals may have impaired the capacity of health care professionals to meet these expectations. In the future, greater attention should also be paid to information exchange to avoid placing unreasonable responsibility on the patient to compensate for deficits in the health care system.

摘要

现在越来越多的患者利用他们的合法权利来阅读自己的病历。我们报告了一项研究的结果,该研究对 17 名挪威成年患者进行了定性访谈,了解他们在住院后要求复印病历的经历。访谈于 2008 年 5 月至 2009 年 4 月之间进行。在定性内容分析的指导下,分析过程确定了两个主要主题:“保持控制感”和“感觉自己不被尊重”。患者阅读自己病历的经历往往与他们在住院期间与医疗保健专业人员直接沟通的经历有关,揭示了信任与权力之间微妙的相互作用。患者希望有更多的信息和知识的相互交流,使他们能够受益于自身健康的管理。我们的结论是,为了满足患者对相互尊重的期望,医院的医疗保健专业人员需要更加注意自己的态度和沟通技巧,以及他们如何行使自己的权力来定义患者的情况。同时,应该更加关注医院组织结构的变化如何削弱了医疗保健专业人员满足这些期望的能力。在未来,应该更加关注信息交流,以避免将不合理的责任强加给患者来弥补医疗保健系统的缺陷。

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