Chimowitz Hannah, Gerard Macda, Fossa Alan, Bourgeois Fabienne, Bell Sigall K
Jt Comm J Qual Patient Saf. 2018 Mar;44(3):130-136. doi: 10.1016/j.jcjq.2017.09.004.
Enabling family/friend caregivers with access to visit notes may help avoid errors, delayed diagnoses, or other ambulatory safety risks. Patient, parent, and caregiver perceptions of how shared notes affect safety behaviors and attitudes were studied in an exploratory study.
To assess the impact of OpenNotes on safety, 24,722 patients with active portal accounts and ≥ 1 available visit notes during the prior year at an urban hospital were surveyed between June and September 2016. Surveys were sent to patient portal accounts, and respondents designated themselves as patients or caregivers. Although the hospital does not have formal proxy portal registration, some patients share access with their caregivers.
Of 24,722 portal accounts accessed during the study, 7,058 (28.5%) surveys were returned, with 150 (2.1%) participants identified as caregivers. Among patients who had tests and referrals, reading notes helped caregivers understand the reason for the test (96/120 [80.0%]) or referral (48/52 [92.3%]), remember to get patient tests done (66/120 [55.0%]), check (98/120 [81.7%]) and understand (98/120 [81.7%]) results, and remember patient appointments (36/52 [69.2%]). As a result of reading notes, 54.1% (59/109) of caregivers helping patients on prescription medications reported better assisting patients to take them correctly. Among note-reading caregivers, 53.7% (n = 72/134) trusted the clinician more (44.8% no change), and 58.2% (n = 78/134) reported better teamwork (41.0% no change) as a result of open notes. In total, 30.3% (n = 40/132) reported at least one mistake or possible mistake in the patient's notes. Finding a possible mistake did not negatively affect trust or teamwork.
OpenNotes may enable caregivers with patient health information, answering the call to better support this critical group in the health care system and to engage patients and families in safety efforts.
让家庭/朋友护理人员能够查看病历可能有助于避免错误、延迟诊断或其他门诊安全风险。在一项探索性研究中，研究了患者、家长和护理人员对共享病历如何影响安全行为和态度的看法。
为评估开放病历对安全性的影响，2016年6月至9月期间，对一家城市医院中24,722名拥有活跃门户账户且上一年至少有一份可用就诊记录的患者进行了调查。调查问卷发送至患者门户账户，受访者将自己指定为患者或护理人员。尽管该医院没有正式的代理门户注册，但一些患者会与他们的护理人员共享访问权限。
在研究期间访问的24,722个门户账户中，有7,058份（28.5%）调查问卷被返回，其中150名（2.1%）参与者被确定为护理人员。在进行了检查和转诊的患者中，阅读病历有助于护理人员理解检查（96/120 [80.0%]）或转诊（48/52 [92.3%]）的原因，记住让患者完成检查（66/120 [55.0%]），查看（98/120 [81.7%]）并理解（98/120 [81.7%]）检查结果，以及记住患者的预约（36/52 [69.2%]）。由于阅读了病历，在帮助患者服用处方药的护理人员中，54.1%（59/109）报告更好地协助患者正确服药。在阅读病历的护理人员中，53.7%（n = 72/134）对临床医生的信任度更高（44.8%无变化），58.2%（n = 78/134）报告由于开放病历，团队合作更好（41.0%无变化）。总体而言，30.3%（n = 40/132）报告在患者病历中至少发现了一个错误或可能的错误。发现可能的错误并未对信任或团队合作产生负面影响。
开放病历可能使护理人员能够获取患者健康信息，响应了更好地支持医疗保健系统中这一关键群体以及让患者和家庭参与安全工作的呼吁。
