メンタルヘルスケアにおけるオープンノートの実施後の文書化の変化:前後の混合方法研究
Eva Meier-Diedrich1,2, Charlotte Blease3, Martin Heinze1,2,4
1Department of Psychiatry and Psychotherapy, Center for Mental Health, Immanuel Hospital Rüdersdorf, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany.
Journal of medical Internet research
|September 3, 2025
まとめ
メンタルヘルスのオープンノートは 患者向けの言語と理解力を高めることで 文書の質を向上させます この変化は 治療関係の透明性と信頼性を高めます
科学分野:
- メンタルヘルスの研究
- 医療情報学
- 臨床文書
背景:
- オープンノートは 患者の臨床文書への デジタルアクセスを提供することで 精神保健医療の透明性と信頼を高めることができます
- 医療従事者 (HCP) の間では,文書の質への潜在的な悪影響について懸念がある.
研究 の 目的:
- 公開ノートを実施した後の臨床文書の客観的および主観的な変化を調べる.
- 精神科の外科医診療所の文書化慣行に対するオープンノートの影響を評価する.
主な方法:
- 16の言語的特徴を用いた876の臨床ノート (実施前と実施後の) の分析.
- 10人の精神科医療従事者との質的インタビューを,反射的なテーマ分析で分析した.
- 定量的な言語分析のために ウィルコクソン署名ランクテストを使用した.
主要な成果:
- 実施後のノートでは,理解性,リソース指向性,感情的ポジティブ性が向上し,汚名や侮辱的な言葉が減少しました.
- 医療従事者は 患者中心のドキュメントの調整を報告し,ジャーゴンを少なく,説明を多くした.
- 医療従事者は,未開封のノートに関するワークフローの調整により,作業量と時間の増加を経験しました.
結論:
- オープンノートの実施は,精神衛生の臨床文書に重大な客観的および主観的な変化をもたらします.
- 臨床医は患者にもっとフレンドリーなノートを目指し,患者と治療同盟に利益をもたらす可能性を示唆しています.
- 持続可能なオープンノートには 効率的なワークフローの統合と 患者中心のドキュメントに関する HCP の教育が必要です
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