在入院后查房时与患者分享书面医疗总结：一项临床医生和患者体验的定性研究。

Sharing a written medical summary with patients on the post-admission ward round: A qualitative study of clinician and patient experience.

机构信息

University of Cambridge Clinical School, Cambridge, UK.

Acute Medicine, Cambridge University Hospital, Cambridge, UK.

出版信息

J Eval Clin Pract. 2021 Dec;27(6):1235-1242. doi: 10.1111/jep.13574. Epub 2021 May 7.

DOI:10.1111/jep.13574

PMID:33960593

Abstract

RATIONALE, AIMS AND OBJECTIVES: Sharing aspects of the traditional medical record with patients has been successful in primary and antenatal care, but has not been investigated in the UK inpatient setting. Our aim was to evaluate the impact on patient and clinician experience of providing patients with a written lay summary of their care-plan in the acute care setting.

METHOD

We carried out a qualitative interview study on two acute medicine wards in an NHS University Teaching Hospital for a 4-week period in 2019. A summary record, designed in response to suggestions from doctors and patients from a previous study, was distributed to patients on the first ward round after admission. Eligible participants included all doctors and nurses working on and all patients and their families attending the acute medical units; patients were excluded if they lacked capacity to consent or were under 18. We interviewed 20 patients, 10 relatives, 10 doctors and 7 nurses.

RESULTS

Patients felt that the summary improved their ability to remember details about their care so they could more accurately and easily update their relatives. They did not feel that the summary induced anxiety. Patient-doctor communication was improved: patients felt empowered to ask more questions and doctors felt that it solidified their plan and encouraged them to avoid medical jargon. Most patients felt the summary included the 'right' amount of information. Healthcare professionals were more concerned about the risk of breaching confidentiality than patients. Doctors felt that providing summaries was time-consuming; there were differing opinions about whether this was a worthwhile investment of time. Clinicians recognized that the traditional medical record has many roles.

CONCLUSIONS

A summary record could empower patients and improve patient-doctor communication but would require additional clinician and administrative time.

摘要

背景、目的和目标：在初级保健和产前保健中，与患者分享传统病历的某些部分已取得成功，但在英国住院环境中尚未进行调查。我们的目的是评估在急性护理环境中为患者提供护理计划书面摘要对患者和临床医生体验的影响。

方法

我们在 2019 年 NHS 大学教学医院的两个急症医学病房进行了为期 4 周的定性访谈研究。根据来自之前研究的医生和患者的建议设计了摘要记录，在入院后的第一次查房时分发给患者。符合条件的参与者包括在急症医学病房工作的所有医生和护士，以及所有患者及其家属；如果患者没有能力同意或年龄在 18 岁以下，则将其排除在外。我们采访了 20 名患者、10 名家属、10 名医生和 7 名护士。

结果

患者认为摘要提高了他们记住护理细节的能力，以便更准确、更轻松地更新亲属。他们并不认为摘要会引起焦虑。患者与医生的沟通得到了改善：患者感到有能力提出更多问题，而医生则认为这巩固了他们的计划，并鼓励他们避免使用医学术语。大多数患者认为摘要包含了“正确”的信息量。医疗保健专业人员比患者更担心违反保密规定的风险。医生认为提供摘要很耗时；对于这是否是对时间的有价值投资存在不同意见。临床医生认识到传统病历有多种作用。