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[1987年在诺德旺的哥本哈根郡立医院获取精神病学和儿童精神病学病例记录]

[Access to psychiatric and child psychiatric case records in the Copenhagen County Hospital in Nordvang in 1987].

作者信息

Svendsen A B, Toftegaard L

出版信息

Ugeskr Laeger. 1989 May 29;151(22):1389-92.

PMID:2734940
Abstract

Commencing on 1.1.1987, all requests for access to case records were registered prospectively in all of the Copenhagen County Hospitals. In the Copenhagen County Hospital, Nordvang, 103 requests were made for access to the case records in the course of 1987. Ninety-five requests in the adult departments resulted in complete access in 90 cases, limited access in one case while access was refused in three cases. One person making the request did not turn up. Eight requests concerning patients in the child psychiatric department resulted in complete access in one case, limited access in five cases while access was refused in two cases. This corresponds to 3.0% in the departments for child psychiatry and 2.7% in the departments for adults. No deterioration in health was observed in any of the 97 cases where access was permitted. In many cases, insight into the case records may, on the other hand, be a good therapeutic measure. On two cases only, access to the case records was given to a third person with the patient's permission, and the majority of the patients did not request a copy of the case records but accepted access to the case records in the form of the right to read the case records with assistance, if necessary. It is concluded that in the first year after introduction of the Danish legislation concerning access to the case records, this ran very smoothly with fewer difficulties than anticipated in a large psychiatric hospital in the region of the capital.

摘要

从1987年1月1日起,哥本哈根郡所有医院都开始对查阅病历的申请进行前瞻性登记。在诺德vang的哥本哈根郡医院,1987年期间有103次查阅病历的申请。成人科室的95次申请中,90例获得完全查阅权,1例获得有限查阅权,3例被拒绝查阅。有1人提出申请后未露面。儿童精神科患者的8次申请中,1例获得完全查阅权,5例获得有限查阅权,2例被拒绝查阅。这相当于儿童精神科的比例为3.0%,成人科室为2.7%。在获准查阅的97例病例中,未观察到任何健康状况恶化的情况。另一方面,在许多情况下,查阅病历可能是一种很好的治疗措施。只有2例在患者允许的情况下将病历提供给了第三方,而且大多数患者没有要求复印病历,而是接受了以在必要时获得协助阅读病历的权利形式查阅病历。得出的结论是,在丹麦关于查阅病历的立法实施后的第一年,进展非常顺利,在首都地区的一家大型精神病医院遇到的困难比预期的要少。

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