Wellcome fellow in society and ethics, The Healthcare Improvement Studies (THIS) Institute, Cambridge, UK and Warwick Medical School, Coventry, UK
University of Cambridge, Cambridge, UK.
Clin Med (Lond). 2019 Sep;19(5):386-391. doi: 10.7861/clinmed.2019-0079.
Patient and professional views about the impact of providing full real-time access to the medical record in the in-hospital setting are unknown.
Likert-scale and free-text validated questionnaire survey of physicians and patients from acute medical units in two hospitals. The questionnaire explored recent experiences; views on the formation of trust, and views on sharing either the entire medical record or a summary.
Two-hundred and forty-eight patient questionnaires (62% response rate) and 32 physician questionnaires (21% response rate) were returned. Twenty-seven per cent of patients did not recall being told their diagnosis. Doctors and patients differed on what practices that they believed built trust.Eighty-one per cent of patients supported the idea of having access to the full medical record (for empowerment; the right to information about oneself; as an for discussion). Doctors feared it might provoke anxiety and change the nature of what was written. A written lay summary record was preferred by doctors and patients.
The current system of providing information verbally to patients is inadequate. Patients want more information and are less concerned than physicians about potential negative effects of real-time access to their records. Patient access to medical records (in both full and summary forms) should be evaluated.
关于在住院环境中提供全面实时访问医疗记录对患者和专业人员的影响，人们知之甚少。
对来自两家医院急性医疗病房的医生和患者进行了李克特量表和自由文本验证的问卷调查。该问卷探讨了他们最近的经历、对信任形成的看法，以及对共享整个医疗记录或摘要的看法。
共收回 248 份患者问卷（62%的回复率）和 32 份医生问卷（21%的回复率）。27%的患者不记得被告知过自己的诊断。医生和患者对哪些做法能建立信任存在分歧。81%的患者支持有机会查阅完整的医疗记录（为了获得授权；获取有关自身的信息的权利；作为讨论的参考）。医生担心这可能会引发焦虑，并改变记录的性质。医生和患者都更喜欢书面的通俗易懂的记录摘要。
目前向患者提供口头信息的系统不够完善。患者希望获得更多信息，他们对实时访问其记录可能产生的负面影响的担忧程度低于医生。应该评估患者对医疗记录的访问权（包括完整记录和摘要）。
