a Center to Improve Veteran Involvement in Care (CIVIC) , VA Portland Health Care System , Portland , OR , USA.
b Department of Psychiatry , Oregon Health & Science University , Portland , OR , USA.
J Ment Health. 2019 Feb;28(1):64-70. doi: 10.1080/09638237.2018.1521924. Epub 2018 Nov 23.
The OpenNotes initiative provides patients online access to their clinical notes. Mental health clinicians in the Veterans Health Administration report a need for guidance on how to provide care, write notes, and discuss them in the context of OpenNotes.
To provide mental health clinicians recommendations identified by patients and clinicians that help them effectively practice in the context of OpenNotes.
Twenty-eight mental health clinicians and 28 patients in mental health care participated in semi-structured interviews about their experiences and perceptions with OpenNotes. A rapid review approach was used to analyze transcripts.
Analysis of interviews identified three domains of advice for mental health clinicians: writing notes that maintain the therapeutic relationship, communicating with patients about their notes and utilizing clinical notes as a patient resource to enhance care. Specific recommendations are provided.
Findings provide mental health clinicians with guidance from service users and clinicians on how to leverage clinical notes to maintain - and potentially enhance -therapeutic relationships in a healthcare system in which patients are able to read their mental health notes online.
OpenNotes 倡议为患者提供了在线访问其临床记录的权限。退伍军人事务部的精神健康临床医生报告称，他们需要指导如何在 OpenNotes 的背景下提供护理、撰写记录并进行讨论。
为精神健康临床医生提供患者和临床医生确定的建议，帮助他们在 OpenNotes 的背景下有效实践。
28 名精神健康临床医生和 28 名接受精神健康护理的患者参与了关于他们在 OpenNotes 方面的经验和看法的半结构化访谈。采用快速审查方法对转录本进行分析。
访谈分析确定了精神健康临床医生的三个建议领域：撰写维护治疗关系的记录、与患者就其记录进行沟通以及将临床记录用作增强护理的患者资源。提供了具体的建议。
研究结果为精神健康临床医生提供了来自服务用户和临床医生的指导，说明如何利用临床记录在患者能够在线阅读其精神健康记录的医疗体系中维护 - 并有可能增强 - 治疗关系。
