the open medical record: an educational tool
Authors: Simonton Mary Jane , Neuffer Cynthia H , Stein Eugene J , Furedy Ronald L 
Published: April 2021

ABSTRACT

Patients on a psychiatric unit of a general hospital were given their complete medical records to read daily, and the practice was evaluated to determine its effect on patients and staff. Both medical and nursing staff, along with patients, found this practice an effective way to educate patients, help the patient become more actively involved in his treatment, correct inaccuracies in the medical record, and promote thoughtful charting by the professional staff.

A widely recognized principle of nursing practice is the active participation of the patient in the management of his health and illness.1 The patient's medical treatment will probably be more effective, and he will be more likely to continue with appropriate therapeutic practices, if he actively participates in planning his care.1-3 Despite wide recognition of this principle, however, medical personnel often fail to put it into practice.3 Usually the patient is the passive recipient of care planned and carried out by the professionals.2 Improving this situation requires changes in the usual relationship between patient and medical personnel. The more responsible the patient is for the management of his care, the more health professionals can focus on teaching and informing.

In order to assume this responsibility effectively, the patient must have usable information about his illness, his diagnosis and what it means, plans for his treatment, the impact his illness and treatment may have on his life style, and his current progress and prognosis. It is crucial that the patient has access to appropriate sources of this information. One important potential source is the medical record.

The patient's medical record has traditionally been a means by which important information about the patient is communicated only among health professionals. Several instances have been recently noted, however, in which patients have been given access to their medical record. 4^ Shenkin and Warner have proposed that legislation be passed to require that current medical records be given to the patient as a matter of practice, the expectation being that the record would serve as an educational tool.8

Sharing responsibility with the patient is a fundamental concept of a therapeutic community.7 Therefore, staff in such a treatment setting might be expected to adapt more readily to the idea of patients having daily access to their medical record. This was the case at Valley General Hospital in Renton, Washington, a 250-bed general hospital with a 15-bed voluntary psychiatric unit, which has a therapeutic community. In keeping with this treatment approach, staff uses various methods that aim at encouraging open communication among patients, and between staff and patients. Patients are expected to assume as much responsibility as possible for their own treatment. To enable patients to be well-informed participants, staff developed a program to make their complete charts available to them. Staff had previously used various methods of giving information to patients which enabled them to take some responsible part in their own treatment. Some physicians read parts of the charts to patients - some occasionally allowed patients to read their own charts. Some staff members questioned whether or not nursing staff had the authority to allow patients to read their own charts - and whether some patients, but not others, should be accorded this privilege. In a weekly staff meeting, the effects on both staff and patients of making charts available to the patients were discussed. Staff members, in general, agreed that open charting was worthy of a trial, although various opinions about it were expressed. A proposal was made to make charts available to patients on a trial basis. An interdisciplinary task force consisting of the authors was appointed to implement and evaluate the effects of open charting on the behavior and attitudes of patients and staff.