Crotty Bradley H, Anselmo Melissa, Clarke Deserae, Elmore Joann G, Famiglio Linda M, Fossa Alan, Flier Lydia, Green Jamie, Klein Jared W, Leveille Suzanne, Lin Chen-Tan, Lyon Corey, Mejilla Roanne, Moles Matthew, Stametz Rebecca A, Thompson Michelle, Walker Jan, Bell Sigall K
J Grad Med Educ. 2018 Jun;10(3):292-300. doi: 10.4300/JGME-D-17-00486.1.
Clinicians are increasingly sharing outpatient visit notes with patients through electronic portals. These open notes may bring about new educational opportunities as well as concerns to physicians-in-training and residency programs.
We assessed anticipatory attitudes about open notes and explored factors influencing residents' propensity toward note transparency.
Residents in primary care clinics at 4 teaching hospitals were surveyed prior to implementation of open notes. Main measures included resident attitudes toward open notes and the anticipated effect on patients, resident workload, and education. Data were stratified by site.
A total of 176 of 418 (42%) residents responded. Most residents indicated open notes would improve patient engagement, trust, and education but worried about overwhelming patients, residents being less candid, and workload. More than half of residents thought open notes were a good idea, and 32% (56 of 176) indicated they would encourage patients to read these notes. More than half wanted note-writing education and more feedback, and 72% (126 of 175) indicated patient feedback on residents' notes could improve communication skills. Attitudes about effects of open notes on safety, quality, trust, and medical education varied by site.
Residents reported mixed feelings about the anticipated effects of sharing clinical notes with patients. They advocate for patient feedback on notes, yet worry about workload, supervision, and errors. Training site was correlated with many attitudes, suggesting local culture drives resident support for open notes. Strategies that address resident concerns and promote teaching and feedback related to notes may be helpful.
临床医生越来越多地通过电子门户与患者共享门诊病历。这些开放病历可能带来新的教育机会，同时也给住院医师和住院医师培训项目带来担忧。
我们评估了对开放病历的预期态度，并探讨了影响住院医师病历透明度倾向的因素。
在4家教学医院的基层医疗诊所实施开放病历之前，对住院医师进行了调查。主要测量指标包括住院医师对开放病历的态度以及对患者、住院医师工作量和教育的预期影响。数据按地点分层。
418名住院医师中有176名（42%）做出了回应。大多数住院医师表示开放病历会提高患者参与度、信任度和教育水平，但担心给患者造成负担、住院医师不够坦诚以及工作量增加。超过一半的住院医师认为开放病历是个好主意，32%（176人中的56人）表示他们会鼓励患者阅读这些病历。超过一半的人希望接受病历书写教育并获得更多反馈，72%（175人中的126人）表示患者对住院医师病历的反馈可以提高沟通技巧。关于开放病历对安全性、质量、信任和医学教育影响的态度因地点而异。
住院医师对与患者共享临床病历的预期效果看法不一。他们主张患者对病历提供反馈，但担心工作量、监督和错误。培训地点与多种态度相关，表明当地文化影响住院医师对开放病历的支持度。解决住院医师担忧并促进与病历相关的教学和反馈的策略可能会有所帮助。
