Abstract
Objective
Allowing psychiatric patients access to their electronic medical record (EMR) may cause difficulty related to the sensitivity of the note content. The authors investigated whether notes written by psychiatry trainees were ready for release to patients.
Methods
Authors conducted a review of 128 PGY-3 to PGY-5 outpatient notes not explicitly marked as “highly confidential.” One psychiatrist and one non-psychiatrist read each note from the patient’s perspective. Reviewers assigned a score of 0–2 (0: No Concern; 1: Some Concern; 2: Major Concern) for each note.
Results
Eighty-nine notes (70%) were assessed as “No Concern” by both reviewers; 30 (23%) were of “Some Concern;” and 9 (7%) were of “Major Concern;” 92 (72%) were deemed of “No Concern ” by a psychiatrist, as compared with 120 (94%) by the non-psychiatrist.
Conclusion
Trainee EMR outpatient notes are not likely to cause major concerns for patients who read them. Psychiatrist-reviewers identified more concerns than non-psychiatrist-reviewers.
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References
Ross SE, Lin CT: The effects of promoting patient access to medical records: a review. J Am Med Inform Assoc 2003; 10: 129–138
Delbanco T, Walker J, Darer JD, et al: Open notes: doctors and patients signing on. Ann Intern Med 2010; 153:121–125
Medicare and Medicaid Programs; Electronic Health Record Incentive Program, Stage 2. 77. Fed Regist 2012; 45:13698-1 3829; available at http://www.gpo.gov/fdsys/pkg/FR-2012-03-07/pdf/2012-4443.pdf
Miller RD, Morrow B, Kaye M, et al: Patient access to medical records in a forensic center: a controlled study. Hosp Community Psychiatry 1987; 38:1081–1085
McFarlane WJ, Bowman RG, MacInnes M: Patient access to hospital records: a pilot project. Can J Psychiatry 1980; 25: 497–502
Parrott J, Strathdee G, Brown P: Patient access to psychiatric records: the patients’ view. J R Soc Med 1988; 81:520–522
Roth LH, Wolford J, Meisel A: Patient access to records: tonic or toxin? Am J Psychiatry 1980; 137:592–596
Stein EJ, Furedy RL, Simonton MJ, et al: Patient access to medical records on a psychiatric inpatient unit. Am J Psychiatry 1979; 136:327–329
Bernadt M, Gunning L, Quenstedt M: Patients’ access to their own psychiatric records. BMJ 1991; 303:967
Kosky N, Burns T: Patient access to psychiatric records: experience in an inpatient unit. Psychiatr Bull 1995; 19:87–90
Salomon RM, Blackford JU, Rosenbloom ST, et al: Openness of patients’ reporting with use of electronic records: psychiatric clinicians’ views. J Am Med Inform Assoc 2010; 17: 54–60
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Kung, S., Lapid, M.I., Swintak, C.C. et al. Survey of Sensitive Information Written in Patient Notes by Psychiatry Trainees. Acad Psychiatry 37, 31–34 (2013). https://doi.org/10.1176/appi.ap.11110195
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DOI: https://doi.org/10.1176/appi.ap.11110195