J Am Med Inform Assoc - Patient-initiated electronic health record amendment requests.

Tópicos

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Resumo

CKGROUND AND OBJECTIVE: Providing patients access to their medical records offers many potential benefits including identification and correction of errors. The process by which patients ask for changes to be made to their records is called an 'amendment request'. Little is known about the nature of such amendment requests and whether they result in modifications to the chart.METHODS: We conducted a qualitative content analysis of all patient-initiated amendment requests that our institution received over a 7-year period. Recurring themes were identified along three analytic dimensions: (1) clinical/documentation area, (2) patient motivation for making the request, and (3) outcome of the request.RESULTS: The dataset consisted of 818 distinct requests submitted by 181 patients. The majority of these requests (n=636, 77.8%) were made to rectify incorrect information and 49.7% of all requests were ultimately approved. In 6.6% of the requests, patients wanted valid information removed from their record, 27.8% of which were approved. Among all of the patients requesting a copy of their chart, only a very small percentage (approximately 0.2%) submitted an amendment request.CONCLUSIONS: The low number of amendment requests may be due to inadequate awareness by patients about how to make changes to their records. To make this approach effective, it will be important to inform patients of their right to view and amend records and about the process for doing so. Increasing patient access to medical records could encourage patient participation in improving the accuracy of medical records; however, caution should be used.

Resumo Limpo

ckground object provid patient access medic record offer mani potenti benefit includ identif correct error process patient ask chang made record call amend request littl known natur amend request whether result modif chartmethod conduct qualit content analysi patientiniti amend request institut receiv year period recur theme identifi along three analyt dimens clinicaldocument area patient motiv make request outcom requestresult dataset consist distinct request submit patient major request n made rectifi incorrect inform request ultim approv request patient want valid inform remov record approv among patient request copi chart small percentag approxim submit amend requestconclus low number amend request may due inadequ awar patient make chang record make approach effect will import inform patient right view amend record process increas patient access medic record encourag patient particip improv accuraci medic record howev caution use

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