Hirschmann Jo, Terry Karen, Van Thyn Rachel, Strano Amy
Center for Spirituality and Health, Mount Sinai Hospital, 1 Gustave L. Levy Place, Box 1036, New York, NY, 10029, USA.
J Relig Health. 2025 Aug 23. doi: 10.1007/s10943-025-02414-3.
In the USA, the 21st Century CURES Act of 2016 requires healthcare providers to give patients online access to their electronic health records. This paper presents recommendations that arose from a three-stage quality improvement process concerning chaplains' note-writing in the era of "open notes." Recommendations included utilizing strengths-based language, avoiding linguistic structures that express disbelief, making notes more concise, and using their notes to continue their care of patients. For chaplains in outpatient oncology clinical settings, additional recommendations take into account the use of phone outreach and the longer-term nature of spiritual care relationships.
在美国，2016年的《21世纪治愈法案》要求医疗服务提供者让患者能够在线访问其电子健康记录。本文提出了在“开放病历”时代，针对牧师书写病历的三阶段质量改进过程中产生的建议。建议包括使用基于优势的语言，避免使用表达怀疑的语言结构，使病历更简洁，并利用病历继续对患者进行护理。对于门诊肿瘤临床环境中的牧师，其他建议考虑了电话 outreach 的使用以及精神护理关系的长期性质。 （注：“outreach”此处可能有误，结合语境推测可能是“外展服务”之类的意思，但按要求未做修改）
