Wibe Torunn, Ekstedt Mirjam, Hellesø Ragnhild, Øyri Karl, Slaughter Laura
Centre for Shared Decision Making and Collaborative Care, Oslo University Hospital, Oslo, Norway.
Stud Health Technol Inform. 2013;192:793-7.
Recent legislation in many countries has given patients the right to access their own patient records. Making health-care professionals' assessments and decisions more transparent by giving patients access to their records is expected to provide patients with useful health information and reduce the power imbalance between patient and provider. We conducted both a mail survey and a face-to-face interview study, including patients who had requested a paper copy of their patient records (EPR), to explore their experiences. For many study participants, a view of their records filled in holes in the oral information they previously received. They had problems understanding parts of what they read, but rarely asked for help. Instead they searched for explanations on the Internet or attempted to understand based on the context. Patients are still afraid of seeming suspicious or displeased if they indicate that they would like to read their records. Health-care organizations should consider actively offering patients the chance to view their clinical documentation to a larger extent than what has been done so far.
许多国家最近颁布的法律赋予了患者查阅自己病历的权利。通过让患者查阅病历，使医疗保健专业人员的评估和决策更加透明，有望为患者提供有用的健康信息，并减少医患之间的权力失衡。我们进行了一项邮件调查和一项面对面访谈研究，研究对象包括那些索要过纸质电子病历（EPR）的患者，以探究他们的经历。对于许多参与研究的患者来说，查看病历填补了他们之前所获口头信息中的空白。他们在理解所读内容的部分信息时存在困难，但很少寻求帮助。相反，他们在互联网上搜索解释内容，或者试图根据上下文来理解。如果患者表示想阅读自己的病历，他们仍然担心显得可疑或不悦。医疗保健机构应考虑比目前更大程度地积极为患者提供查看其临床文档的机会。
