Jones R B, Hedley A J, Allison S P, Tattersall R B
J R Coll Gen Pract. 1988 Mar;38(308):117-8.
Computer-held information is increasingly shared between general practice and hospitals and with the provisions of the Data Protection Act now in operation, the practical issues of disclosure to patients need to be reviewed. Patients attending diabetic clinics at University Hospital, Nottingham, are routinely issued with a copy of their computerheld record but a previous study showed a high level of censoring by the hospital doctors. This paper reports a review of a sample of 251 censored records, containing 426 problems, whereby the doctors concerned provided reasons for the censoring and restored information they thought suitable. After the review, only 8% of censored problems, that is 1% of all problems, remained censored. An additional 2% of all problems were deleted from the patient's copy at the request of the patient. It is essential that systems which allow censoring of patient records have continuous built-in audit to monitor the reasons for censoring.
计算机保存的信息在全科医疗和医院之间越来越多地共享，随着《数据保护法》的实施，向患者披露信息的实际问题需要重新审视。在诺丁汉大学医院糖尿病诊所就诊的患者通常会收到一份其计算机保存记录的副本，但之前的一项研究表明，医院医生进行了大量审查。本文报告了对251份经审查记录样本的回顾，这些记录包含426个问题，相关医生为审查提供了理由，并恢复了他们认为合适的信息。审查后，只有8%的审查问题（即所有问题的1%）仍被审查。应患者要求，又有2%的所有问题从患者副本中删除。允许对患者记录进行审查的系统必须有持续的内置审核，以监控审查的原因。
