在图表注释中使用患者引用:从临床伦理学的角度来看
The Journal of clinical ethics
|November 22, 2023
概括
"21世纪治疗法"要求患者通过OpenNotes实时访问电子病历. 这需要临床医生重新评估引文实践,平衡利益与潜在风险,以改善患者沟通.
科学领域:
- 医疗保健政策 医疗保健政策
- 临床伦理学 临床伦理学
- 医疗信息学 医疗信息学
背景情况:
- 在2021年颁布的"21世纪治疗法"中,包括了OpenNotes指令.
- 该指令规定,患者及其代表必须能够实时访问电子病历.
- 这一政策转变需要对当前的临床图表实践进行审查.
研究的目的:
- 分析在OpenNotes下直接在电子病历中引用患者的风险和益处.
- 为临床伦理学家提供有关如何处理与患者报价相关的图表编制实践的指导.
- 在医疗保健团队中促进更具反射性和道德性的图表行为.
主要方法:
- 讨论与临床笔记中直接引用相关的风险和益处.
- 探索OpenNotes对患者记录访问的影响.
- 为临床伦理学家确定策略,以减轻引用患者的潜在危害.
主要成果:
- 直接引用,虽然看起来很清楚,但在患者记录文档中可能存在固有的风险.
- 开放笔记政策提出了改善临床沟通和文档的挑战和机会.
- 临床伦理学家可以在指导团队更深思熟虑地绘制图表方面发挥关键作用.
结论:
- 反射图表实践是必不可少的,特别是关于在OpenNotes下使用患者报价的做法.
- 伦理学家可以主动指导医疗保健团队,以导航患者记录访问和文档的复杂性.
- 在现代临床文档中,平衡透明度,患者隐私和准确的代表性是关键.
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