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向住院患者及其家属提供医生每日病程记录以改善患者体验。

Giving Doctors' Daily Progress Notes to Hospitalized Patients and Families to Improve Patient Experience.

作者信息

Weinert Craig

机构信息

1 University of Minnesota, Minneapolis, MN.

出版信息

Am J Med Qual. 2017 Jan/Feb;32(1):58-65. doi: 10.1177/1062860615610424. Epub 2016 Jul 9.

Abstract

Hospital quality includes excellent physician-patient communication. The objective was to determine effects of distributing physicians' notes to patients. Hospitalized patients or family members on 6 wards at a university hospital received daily a printed copy of their medical team's progress note. Surveys were completed about the benefits and adverse effects of reading the physician notes. In all, 74% to 86% of patients or family members responded favorably that receiving doctors' notes improved understanding of their health condition or gave them more control over their hospital course. Patient concerns about privacy or offense were uncommon, although 16% thought notes were confusing or caused worry. Note distribution had minor effects on physician note writing practice. Having patients and family members read their physicians' progress notes is feasible and enhances patients' understanding of their diagnostic and treatment plan. Notes supplement traditional physician-patient verbal communication practice and have the potential to improve the hospitalized patient experience.

摘要

医院质量包括良好的医患沟通。目的是确定向患者分发医生记录的效果。一所大学医院6个病房的住院患者或家属每天收到其医疗团队病程记录的打印件。就阅读医生记录的益处和不良影响完成了调查。总体而言,74%至86%的患者或家属给出了积极回应,即收到医生记录增进了他们对自身健康状况的了解,或使他们对自己的住院过程有了更多掌控。患者对隐私或冒犯的担忧并不常见,尽管16%的人认为记录令人困惑或引发担忧。分发记录对医生书写记录的习惯影响较小。让患者及其家属阅读医生的病程记录是可行的,且能增强患者对其诊断和治疗方案的理解。记录补充了传统的医患口头沟通方式,并有改善住院患者体验的潜力。

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