Clinical documentation as a source of information for patients - possibilities and limitations

Stud Health Technol Inform. 2013;192:793-7.

Abstract

Recent legislation in many countries has given patients the right to access their own patient records. Making health-care professionals' assessments and decisions more transparent by giving patients access to their records is expected to provide patients with useful health information and reduce the power imbalance between patient and provider. We conducted both a mail survey and a face-to-face interview study, including patients who had requested a paper copy of their patient records (EPR), to explore their experiences. For many study participants, a view of their records filled in holes in the oral information they previously received. They had problems understanding parts of what they read, but rarely asked for help. Instead they searched for explanations on the Internet or attempted to understand based on the context. Patients are still afraid of seeming suspicious or displeased if they indicate that they would like to read their records. Health-care organizations should consider actively offering patients the chance to view their clinical documentation to a larger extent than what has been done so far.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Data Collection
  • Documentation / statistics & numerical data*
  • Electronic Health Records / statistics & numerical data*
  • Health Records, Personal*
  • Humans
  • Middle Aged
  • Norway
  • Patient Access to Records / statistics & numerical data*
  • Patient Education as Topic / statistics & numerical data*
  • Patient Participation / statistics & numerical data*
  • Patient Satisfaction / statistics & numerical data*
  • Young Adult