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Patient Accessible Electronic Health Records: Impacts on Nursing Documentation Practices at a University Hospital

机译：患者可访问的电子健康记录：对大学医院的护理文件实践的影响

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In a Norwegian health region, patients have online access to their own electronic health record and they can also read the nursing documentation. This paper presents a qualitative study made at a university hospital to investigate how patient accessible electronic health records impact on nursing documentation practices. Semi-structured interviews were made with 12 informants from 5 cardiology departments at one hospital regarding how they used electronic nursing documentation in their daily practice and how they experienced patient accessible nursing documentation. The nurses emphasized that they focused on a clear and well-written nursing documentation, but in some situations, they were hesitant to write sensitive information. The study concluded that the implementation of patients' reading access to the electronic health record had limited impact on the nursing documentation and the daily practice at the departments, but the nursing handover had an even more important function for oral exchange of information.
机译：在挪威卫生地区，患者在线访问自己的电子健康记录，他们也可以阅读护理文件。本文介绍了大学医院的定性研究，以调查耐心电子健康记录如何对护理文件实践的影响。有关一家医院的5个心脏病学部门的12个线人在一家关于他们在日常练习中使用电子护理文件以及他们经历过患者可访问的护理文件的情况，有12个内部人员采访。护士强调，他们专注于一个清晰良好的护理文件，但在某些情况下，他们犹豫不决写敏感信息。该研究得出结论，患者阅读对电子健康纪录的读取机会对护理文件的影响有限，部门的日常练习有限，但护理切换有一个更重要的信息职能。

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