精神病医生对与实施开放笔记相关的条件和后果的看法:定性调查
Julian Schwarz1,2, Cosima Hoetger3, Lena-Sophie Pluschke4,5
1Department of Psychiatry and Psychotherapy, Center for Mental Health, Immanuel Hospital Rüdersdorf, Brandenburg Medical School Theodor Fontane, Seebad 82/83, Rüdersdorf, DE, Germany. julian.schwarz@mhb-fontane.de.
BMC psychiatry
|June 10, 2024
概括
心理健康的开放性说明提供了诸如增加患者参与等好处,但需要仔细规划. 精神病医生建议对诊断,时间,资源和隐私的指导方针对于成功实施至关重要.
科学领域:
- 心理健康 心理健康
- 医疗信息学 医疗信息学
- 精神病学是一个精神病学.
背景情况:
- 患者对临床笔记的访问,称为开放笔记,正在全球扩大.
- 心理健康的开放性注释是有争议的,对患者的参与有潜在的好处,以及痛苦或污名化的风险.
研究的目的:
- 探讨精神病学家对德国成功实施开放笔记的条件的观点.
- 了解对工作量和治疗结果的预期影响.
主要方法:
- 用德国18名精神病医生的半结构面试进行定性研究设计.
- 对面试数据进行主题分析.
主要成果:
- 确定了四个关键的实施条件:诊断/严重性,备注/讨论时间,资源/系统兼容性和法律/数据保护.
- 文件,治疗和医生与患者互动的预期变化.
- 预期的好处包括提高透明度和信任,但存在由于误解导致关系恶化的风险.
结论:
- 德国的精神病医生支持开放注释,但有保留,根据患者的特征预计会产生不同的影响.
- 关于访问管理,时间,可用性和隐私的明确准则是必不可少的.
- 开放的笔记可能会提高透明度和参与度,但也可能导致耻辱和冲突.
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