Chung Rebecca K, Kim Una Olivia, Basir Mir Abdul
a University of Iowa Health Care , Iowa City , IA , USA.
b Medical College of Wisconsin and Children's Hospital of Wisconsin , Milwaukee , WI , USA.
J Matern Fetal Neonatal Med. 2018 Apr;31(8):1078-1084. doi: 10.1080/14767058.2017.1306853. Epub 2017 Apr 10.
To improve informed medical decision-making, principles for family-centered neonatal care recommend that parents have access to their child's medical record on an ongoing basis during neonatal intensive unit care (NICU) hospitalization. Currently, many NICUs do not allow independent parent access to their child's electronic medical record (EMR) during hospitalization. We undertook a cross-sectional survey pilot study of medical professionals and parents to explore opinions regarding this practice.
Inclusion criteria: 18-years old, English-literate, legal guardian of patients admitted to the NICU for 14 days. NICU medical professionals included physicians, nurse practitioners, nurses, and respiratory therapists.
Medical professionals believed parent access would make their work more difficult, increase time documenting and updating families, making them more liable to litigation and hesitant to chart sensitive information. However, parents felt that they lacked control over their child's care and desired direct access to the EMR. Parents believed this would improve accuracy of their child's medical chart, and increase advocacy and understanding of their child's illness.
NICU parents and medical professionals have differing perspectives on independent parental access to their child's EMR. More research is needed to explore the potential of independent parental EMR access to further improve family-centered neonatal care.
为改善明智的医疗决策，以家庭为中心的新生儿护理原则建议，在新生儿重症监护病房（NICU）住院期间，父母应能持续获取其孩子的病历。目前，许多NICU在住院期间不允许父母独立获取其孩子的电子病历（EMR）。我们对医疗专业人员和父母进行了一项横断面调查试点研究，以探讨对这种做法的看法。
纳入标准：年龄在18岁及以上、具备英语读写能力、为入住NICU达14天的患者的法定监护人。NICU医疗专业人员包括医生、执业护士、护士和呼吸治疗师。
医疗专业人员认为，父母获取病历会使他们的工作更困难，增加记录和向家庭更新信息的时间，使他们更易面临诉讼，并且在记录敏感信息时会犹豫不决。然而，父母觉得他们对孩子的护理缺乏掌控，希望能直接访问电子病历。父母认为这将提高孩子病历的准确性，并增强对孩子病情的支持和了解。
NICU的父母和医疗专业人员在父母独立访问其孩子的电子病历这一问题上存在不同观点。需要开展更多研究，以探索父母独立访问电子病历的潜力，从而进一步改善以家庭为中心的新生儿护理。
