What Happens When Hospitalized Patients See Their Own Records DAVID P. STEVENS, M.D.; RHONDA STAGG, R.N.; and IAN R. MACKAY, M.D., F.R.C.P., F.R.A.C.P.; Melbourne, Australia
The effect of giving hospitalized medical patients access to their problem-oriented hospital records was investigated. Twenty-five subjects were given free access to their records while 25 other subjects served as controls. Few of the open record group actively sought and studied their records; most elected to see them only as part of routine ward rounds; and one objected to seeing the record at all. Taking the experimental group as a whole, there was no measurable effect of seeing the record on the subjects' ability to list their diagnoses or medications, their self-assessment of depression, anxiety or contentment, or their attitudes toward selected components of the health care system. On the other hand, in individual instances access to the hospital record seemed to facilitate communication and provide an opportunity for hospital inpatients to monitor objectively their hospital course.
was staffed by three resident physicians while three full-time attending physicians supervised the care of patients. Approximately one half of the patients were assigned to this ward by the hospital admitting office as part of the random rotation of admissions; consequently, these patients had no choice of their resident physicians. The remainder of the patients were long-term continuing patients of the unit who had been referred originally because of the known research interests of the senior attending staff. HOSPITAL RECORD: THE PROBLEM-ORIENTED MEDICAL SYNOPSIS
The day-to-day progress record in this ward was the ProblemOriented Medical Synopsis, which was developed in this unit (6). It constituted the working record for each patient and consisted of a three-page fold-out sheet. The ward resident listed each of the patient's problems on the left side of the sheet followed horizontally by the relevant history, physical signs, laboratory tests and results, consultants' opinions, and drugs. On the reverse side were recorded progress notes, social history, and past history. The entire hospital record for each patient was recorded in one self-contained three-page sheet. CRITERIA FOR INCLUSION
I T HAS BEEN ADVOCATED (1-4) that patients should have
easy access to part or all of their medical records, particularly in the ambulatory setting; however, there is little objective evidence that this approach merits wide acceptance. Patients' knowledge of the content of their records should facilitate communication between doctors and patients. On the other hand, such knowledge might increase the patient's anxiety about his or her illness or compromise possible benefits of the placebo effect on certain therapies (5). We report here our initial experience with exposure of acutely ill patients to their own problem-oriented records. Our hypothesis in undertaking this study was twofold: an "open-record" is feasible, and it should facilitate communication between patients and doctors. We sought to ascertain the feasibility of an "open-record" in an in-patient setting; its acceptability to patients and health care personnel; its effect on patients' attitudes toward the health care system; and its effect on communication between doctor and patient. Methods STUDY POPULATION
This study was conducted in the Clinical Research Unit of the Royal Melbourne Hospital, a 27-bed public ward. The unit • From the Clinical Research Unit, Royal Melbourne Hospital and Walter and Eliza Hall Institute of Medical Research; Melbourne, Australia.
474
Downloaded from https://annals.org by Tulane University user on 01/06/2019
All patients admitted within a 5-month period were considered for inclusion in the study. Within 24 h of admission a 5-minute test was administered to each patient that included a short paragraph in English asking the patient's name and the date. In addition, the first six figures of the Raven's Progressive Matrices were presented to the patient for completion (7). These tests established admission to the study on the basis of orientation to self and time, and the ability to comprehend written English and to complete elementary intellectual tasks. EXPOSURE TO PATIENTS' RECORDS
The open-record group was designated as all men admitted to the study during its first 75 days and all women during the second 75 days. The opposite sex constituted the control group during either period. Thus, all patients in a particular four-bed ward were in either the experimental or control group. It was impossible to "blind" the ward personnel to identification of the experimental or control group. After determining inclusion in the study, each patient who was allocated to the open-record group was visited by the ward research nurse, who explained the format of the Problem Oriented Medical Synopsis to the patient and advised that the record was available for examination at any time upon request. Questions and comments about its contents were invited. Subsequently, whenever a doctor visited the patient's bedside to discuss the patient's problems, the record was opened and oriented toward the patient. Patients in the control group were treated conventionally with respect to communication with the hospital staff. The contents of the record were kept from the patient's view, and information about the patient's illness was communicated in the usual edited form by physicians and nurses. Annals of Internal Medicine 86:474-477, 1977
EVALUATION OF PATIENT'S RESPONSE TO THE RECORD
All patients completed an admission test battery that included three components. First, the patient was asked to list all his or her health problems and medicines along with their doses. Second, each patient indicated a self-assessment of mood, level of anxiety, and contentment on a linear scale. For example, the patient's assessment of anxiety was ascertained by placing a mark on a linear scale that had at one end the statement "the most anxious I have ever been" and at the other end "the least anxious I have ever been." The distance from the left end of the 10-cm line was measured in centimetres, and that distance became the numerical score for the patient's assessment of anxiety. Third, the patient completed the Semantic Differential (8), a test in which the respondent rated six components of the health care system on the basis of his or her opinion of their value, comprehensibility, potency, and complexity. The six components that were evaluated were the patient's doctor, nurses, hospital, illness, medicines, and self. At discharge, the same three-part test battery was administered again to ascertain changes in the patient's understanding of his or her health problems, medicines, affect, and attitudes toward selected components of the health care system. OBSERVATIONS OF PATIENT-PHYSICIAN INTERACTION
Daily observations were made by the authors of spontaneous interactions between patients and health care personnel to determine the effect on care of using the record as the focus of communication. These observations were, of course, subjective and open to bias, but they provided a record of these interactions that might not be reflected by the test battery. STATISTICAL METHODS
The open-record and control groups were compared by the following methods: for sex, age, and number of problems using the standard /-test for independent samples testing the differences between means, assuming equal variances; for the ability to recall medical problems and medicines by the chisquare test on the proportion remembered; for changes between admission and discharge scores of self-assessment of affect by the standard /-test; and for scores achieved on the Semantic Differential by multiple /-tests. So many /-tests were done in the evaluation of the Semantic Differential that only a P value of less than 0.01 was acceptable as excluding an effect of chance (8). Results STUDY POPULATION
Of 168 persons admitted to this unit during the study period, 64 met the criteria for inclusion in the study. One hundred four were excluded for the following reasons: 52 failed to achieve an acceptable score on the Raven's Progressive Matrices, 21 could not read English, 20 were unable to take the test for medical reasons (for example, blindness), eight refused to participate, and three were excluded for other miscellaneous reasons. Of the 64 included, 14 did not complete all aspects of evaluation; most of these did not complete the discharge questionnaire. Of the 50 patients remaining in the study, 25 were in the open-record group and 25 in the control group. There were no significant differences between the experimental and control groups for sex, age, and number of problems on the doctor's problem list (Table 1). A wide range of general medical problems were seen (Table 1); many reflected the major research interests of the unit.
Table 1. Comparison of Experimental and Control Groups
Subjects Males Mean age (range), yrs Mean problems per patient Principle Diagnosis Immunopathic disease* Cancer/lymphoma Gastrointestinal hemorrhage Cardiac arrhythmia Thyrotoxicosis Myocardial infarction Epilepsy Other diagnoses f
Open-Record
Control
25 12 42.2 (17-70) 4.8
25 13 45.1 (22-7: 4.5
5 2 2 1 1 0 3 11
4 3 2 1 1 4 0 10
* Systemic lupus erythematosus, rheumatoid arthritis, Sjbgrens disease, chronic active hepatitis. t There was one subject with each of these diagnoses.
offered the opportunity to follow the course of their illness by means of an open record, seven requested their records for study at times other than formal ward rounds, 17 passively accepted their records on rounds but did not ask for them at other times, and one refused to see her record when offered it, insisting that she be told her problems by her doctors. Because of the wide variety of medical problems relative to the small number of subjects (Table 1), no conclusions could be drawn regarding the effect of diagnosis on acceptance of the open-record. EFFECT OF AN OPEN-RECORD ON PATIENTS' KNOWLEDGE OF HEALTH PROBLEMS, AFFECTS, AND ATTITUDES TOWARD HEALTH CARE
As an overall indication of retention of information, the ability to recall medical problems and medicines at time of discharge was compared between the control and experimental group (Table 2 ) . Persons in the open-record group listed a mean of 1.4 out of 4.3 ( 2 9 % ) problems at discharge, while those in the control group listed 1.1 out of 4.5 (24% ). These figures were not significantly different. Both groups could recall three quarters of their drugs by name and dose without assistance. Changes between admission and discharge scores of self-assessment of depression, anxiety, and contentment were remarkably similar in the open-record and control groups. The respective scores in the open-record and control groups were - 0 . 6 1 ± 0.37 and - 0 . 6 0 ± 0.36 for depression, 0.08 ± 0.47 and - 0 . 7 3 ± 0.55 for anxiety, and 0.95 ± 0.42 and 1.28 ± 0.37 for contentment. The mean differences in all three categories between the two groups were not significantly different. Comparisons of attitudes toward doctors, nurses, hospitals, medication, illness, and self showed no significant differences between the open-record group and the control group when measured by the Semantic Differential. In all comparisions the value of P was greater than 0.01. OBSERVATIONS
ACCEPTANCE OF AN OPEN-RECORD
INTERACTION
Of the 25 persons in the experimental group who were
Daily
OF
PATIENT-HEALTH
CARE
observations of patient-health
care
PERSONNEL
personnel
Stevens et a/ • Patients and Hospital Records
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475
Table 2. Problems and Medicines Recalled by Patients at Discharge
Problems Open-record Control Medicines Open-record Control
Mean Total Listed by Patient
Mean Total on Record
Percent Recalled by Patients
1.4 1.1
4.8 4.5
29 24
1.6 1.2
2.1 1.6
76 75
interaction around the open record may be summarized in the following generalizations. When appropriate, examples are given. 1. Information exchange appeared to be facilitated in selected instances. A surprising observation was that two persons with chronic disease in which the etiology was poorly understood by the physician, that is, chronic active hepatitis in one instance and systemic lupus erythematosus in the other, expressed the fear that they in fact had cancer, even when such a fear was totally unfounded. The existence of their fears was in both instances not suspected by the physician. Such fears were not detected by the experimental questionnaire, nor were they expressed to the staff physician until the record was reviewed by the patient. Review of the record provided both a focus for discussion and evidence to clarify the diagnoses for the patients. 2. The record was a single constant source of information for the patient on a ward where as many as six doctors and numerous medical students and nurses communicated with the patient or expressed varying opinions within hearing range of the patient. 3. Differences in medical and lay vocabulary were highlighted by discussions that were prompted by review of the record. One corpulent patient was surprised to find "obesity" listed as a diagnosis. She initially objected to its inclusion because she thought that it represented a critical comment about her appearance. Hopefully insight grew out of a discussion of the potential risks of diabetes and coronary artery disease. 4. The open-record provided an opportunity for audit of immediate medical care by the patient. Review of the record permitted the patient's comment on whether the doctor's list of problems were the same problems that were disturbing the patient. A few patients actively contributed to the data base and monitored its accuracy. An example of this was one pregnant woman who noted the incorrect recording of her blood type where, in fact, an Rh incompatibility existed. As a result, passive immunization was achieved by the appropriate administration of antirhesus antibodies at the time of delivery. 5. Physicians frequently claimed that the time required to deal adequately with discussion raised by patients' seeing their own records exceeded the time normally required for discussion when it was more controllable by the physician. Unfortunately, actual measurements of time at bedside were not made prospectively as part of this study. 6. Conditioned roles that doctors and patients employ in relating to each other initially resulted in awkward 476
discussion around the open-record; doctors needed frequent reminders that a particular patient was in the open-record group. 7. Practical communication problems that interfered with patients' understanding their records included medical abbreviations, vocabulary, and individual doctors' handwriting. 8. Most doctors have developed their own individual style of communication with patients that best fits the doctors personality; the introduction of an open-record at the bedside inevitably forced alteration in this style and met varying amounts of resistance. Similarly, it could not be determined to what extent knowledge that the record might be reviewed by the patient affected the content of the record. Discussion
The open problem-oriented record was introduced into the ward routine in a teaching hospital and its acceptance assessed. As might be expected, there were predictable and substantial obstacles encountered in attempting to implement an open hospital record despite the use of a problem-oriented synopsis that presented information to the patient in a concise and organized form. All patients did not greet the opportunity to view their records with enthusiasm. Many were unable to cope with the record for practical reasons such as intelligence, language difficulties, or their infirmity; others did not wish to part with the emotionally protective convention of leaving the interpretation of their illnesses to their doctors. Furthermore, health care personnel did not always alter willingly their traditional approach, which tended to maintain their control of the interview situation. Several authors convincingly have advocated implementation of an open-record in the ambulatory care setting (1, 3, 4 ) . It may be argued, however, that its application in the inpatient setting might worsen anxiety already made high by symptoms, an unfamiliar setting, and new diagnostic and therapeutic procedures. This concern was not borne out by the results of our study. Neither patient's affect nor attitudes toward various aspects of the health care system appeared to be altered measurably. Implementation of the open-record, however, resulted in numerous individual instances not reflected in responses to the questionnaire where the availability of the record facilitated communication between patient and physician. This facilitation seemed to result from both the record itself and from discussion stimulated by the presence and content of the record. The results of this study suggest that the opportunity to review a problem-oriented hospital record might be offered to all patients with a modest level of intelligence and ability to read and that the patients' preferences are appropriate to determine patients' access to their own medical records, provided that health care personnel are aware that what they write may be reviewed by their patients.
Apr//1977 • Annals of Internal Medicine • Volume 86 • Number 4
Downloaded from https://annals.org by Tulane University user on 01/06/2019
ACKNOWLEDGMENTS: The authors thank Ms. Katherine Sanders for suggestions in the design of the study and Dr. Naomi Breslau for review of the paper. Dr. Stevens was Cleveland Fellow
to the Royal Melbourne Hospital. Dr. Mackay is supported by a grant from the National Health and Medical Research Council of Australia. Received 11 June 1976; revision accepted 11 October 1976. • Requests for reprints should be addressed to David P. Stevens, M.D.; University Hospitals; Cleveland, OH 44106. References 1. BJORN JC, CROSS H D : Problem Oriented Practice. Chicago, Modern Hospital Press, 1970 2. HERTZ CG, BERNHEIM JW, PERLOFF TN: Patient participation in
the problem-oriented system: a health care plan. Med Care 14: 77-79, 1976 3. SHENKIN BN, WARNER DC: Giving the patient his medical
record: a proposal to improve the system. N Engl J Med 289: 688-692, 1973 4. BOUCHARD RE, TUFO HM, VAN BUREN HC, et al: The patient
and his problem-oriented
record, in Applying
the Problem-
Oriented System, edited by WALKER HK, HURST JW, WOODY MF.
New York, Medcom Press, 1973, pp. 42-46 5. MOERTEL CG, TAYLOR WF, ROTH A, et al: Who responds to
sugar pills? Mayo Clin Proc 51:96-100, 1976 6. GLEDHILL VX, MACKAY IR, MATHEWS JD, et al: The problem-
oriented medical synopsis. Applications to patient care, education, and research. Ann Intern Med 78:685-691, 1973 7. RAVEN JC: Raven's Progressive Matrices. Melbourne, The Australian Council for Educational Research, 1938 8. OSGOOD CE, SUCI GJ, TANNENBAUM PH: The Measurement of
Meaning. Urbana, University of Illinois Press, 1957
Stevens et a/. • Patients and Hospital Records
Downloaded from https://annals.org by Tulane University user on 01/06/2019
477
The effect of giving hospitalized medical patients access to their problem-oriented hospital records was investigated. Twenty-five subjects were given free access to their records while 25 other subjects served as controls. Few of the open record group actively sought and studied their records; most elected to see them only as part of routine ward rounds; and one objected to seeing the record at all. Taking the experimental group as a whole, there was no measurable effect of seeing the record on the subjects' ability to list their diagnoses or medications, their self-assessment of depression, anxiety or contentment, or their attitudes toward selected components of the health care system. On the other hand, in individual instances access to the hospital record seemed to facilitate communication and provide an opportunity for hospital inpatients to monitor objectively their hospital course.
was staffed by three resident physicians while three full-time attending physicians supervised the care of patients. Approximately one half of the patients were assigned to this ward by the hospital admitting office as part of the random rotation of admissions; consequently, these patients had no choice of their resident physicians. The remainder of the patients were long-term continuing patients of the unit who had been referred originally because of the known research interests of the senior attending staff. HOSPITAL RECORD: THE PROBLEM-ORIENTED MEDICAL SYNOPSIS
The day-to-day progress record in this ward was the ProblemOriented Medical Synopsis, which was developed in this unit (6). It constituted the working record for each patient and consisted of a three-page fold-out sheet. The ward resident listed each of the patient's problems on the left side of the sheet followed horizontally by the relevant history, physical signs, laboratory tests and results, consultants' opinions, and drugs. On the reverse side were recorded progress notes, social history, and past history. The entire hospital record for each patient was recorded in one self-contained three-page sheet. CRITERIA FOR INCLUSION
I T HAS BEEN ADVOCATED (1-4) that patients should have
easy access to part or all of their medical records, particularly in the ambulatory setting; however, there is little objective evidence that this approach merits wide acceptance. Patients' knowledge of the content of their records should facilitate communication between doctors and patients. On the other hand, such knowledge might increase the patient's anxiety about his or her illness or compromise possible benefits of the placebo effect on certain therapies (5). We report here our initial experience with exposure of acutely ill patients to their own problem-oriented records. Our hypothesis in undertaking this study was twofold: an "open-record" is feasible, and it should facilitate communication between patients and doctors. We sought to ascertain the feasibility of an "open-record" in an in-patient setting; its acceptability to patients and health care personnel; its effect on patients' attitudes toward the health care system; and its effect on communication between doctor and patient. Methods STUDY POPULATION
This study was conducted in the Clinical Research Unit of the Royal Melbourne Hospital, a 27-bed public ward. The unit • From the Clinical Research Unit, Royal Melbourne Hospital and Walter and Eliza Hall Institute of Medical Research; Melbourne, Australia.
474
Downloaded from https://annals.org by Tulane University user on 01/06/2019
All patients admitted within a 5-month period were considered for inclusion in the study. Within 24 h of admission a 5-minute test was administered to each patient that included a short paragraph in English asking the patient's name and the date. In addition, the first six figures of the Raven's Progressive Matrices were presented to the patient for completion (7). These tests established admission to the study on the basis of orientation to self and time, and the ability to comprehend written English and to complete elementary intellectual tasks. EXPOSURE TO PATIENTS' RECORDS
The open-record group was designated as all men admitted to the study during its first 75 days and all women during the second 75 days. The opposite sex constituted the control group during either period. Thus, all patients in a particular four-bed ward were in either the experimental or control group. It was impossible to "blind" the ward personnel to identification of the experimental or control group. After determining inclusion in the study, each patient who was allocated to the open-record group was visited by the ward research nurse, who explained the format of the Problem Oriented Medical Synopsis to the patient and advised that the record was available for examination at any time upon request. Questions and comments about its contents were invited. Subsequently, whenever a doctor visited the patient's bedside to discuss the patient's problems, the record was opened and oriented toward the patient. Patients in the control group were treated conventionally with respect to communication with the hospital staff. The contents of the record were kept from the patient's view, and information about the patient's illness was communicated in the usual edited form by physicians and nurses. Annals of Internal Medicine 86:474-477, 1977
EVALUATION OF PATIENT'S RESPONSE TO THE RECORD
All patients completed an admission test battery that included three components. First, the patient was asked to list all his or her health problems and medicines along with their doses. Second, each patient indicated a self-assessment of mood, level of anxiety, and contentment on a linear scale. For example, the patient's assessment of anxiety was ascertained by placing a mark on a linear scale that had at one end the statement "the most anxious I have ever been" and at the other end "the least anxious I have ever been." The distance from the left end of the 10-cm line was measured in centimetres, and that distance became the numerical score for the patient's assessment of anxiety. Third, the patient completed the Semantic Differential (8), a test in which the respondent rated six components of the health care system on the basis of his or her opinion of their value, comprehensibility, potency, and complexity. The six components that were evaluated were the patient's doctor, nurses, hospital, illness, medicines, and self. At discharge, the same three-part test battery was administered again to ascertain changes in the patient's understanding of his or her health problems, medicines, affect, and attitudes toward selected components of the health care system. OBSERVATIONS OF PATIENT-PHYSICIAN INTERACTION
Daily observations were made by the authors of spontaneous interactions between patients and health care personnel to determine the effect on care of using the record as the focus of communication. These observations were, of course, subjective and open to bias, but they provided a record of these interactions that might not be reflected by the test battery. STATISTICAL METHODS
The open-record and control groups were compared by the following methods: for sex, age, and number of problems using the standard /-test for independent samples testing the differences between means, assuming equal variances; for the ability to recall medical problems and medicines by the chisquare test on the proportion remembered; for changes between admission and discharge scores of self-assessment of affect by the standard /-test; and for scores achieved on the Semantic Differential by multiple /-tests. So many /-tests were done in the evaluation of the Semantic Differential that only a P value of less than 0.01 was acceptable as excluding an effect of chance (8). Results STUDY POPULATION
Of 168 persons admitted to this unit during the study period, 64 met the criteria for inclusion in the study. One hundred four were excluded for the following reasons: 52 failed to achieve an acceptable score on the Raven's Progressive Matrices, 21 could not read English, 20 were unable to take the test for medical reasons (for example, blindness), eight refused to participate, and three were excluded for other miscellaneous reasons. Of the 64 included, 14 did not complete all aspects of evaluation; most of these did not complete the discharge questionnaire. Of the 50 patients remaining in the study, 25 were in the open-record group and 25 in the control group. There were no significant differences between the experimental and control groups for sex, age, and number of problems on the doctor's problem list (Table 1). A wide range of general medical problems were seen (Table 1); many reflected the major research interests of the unit.
Table 1. Comparison of Experimental and Control Groups
Subjects Males Mean age (range), yrs Mean problems per patient Principle Diagnosis Immunopathic disease* Cancer/lymphoma Gastrointestinal hemorrhage Cardiac arrhythmia Thyrotoxicosis Myocardial infarction Epilepsy Other diagnoses f
Open-Record
Control
25 12 42.2 (17-70) 4.8
25 13 45.1 (22-7: 4.5
5 2 2 1 1 0 3 11
4 3 2 1 1 4 0 10
* Systemic lupus erythematosus, rheumatoid arthritis, Sjbgrens disease, chronic active hepatitis. t There was one subject with each of these diagnoses.
offered the opportunity to follow the course of their illness by means of an open record, seven requested their records for study at times other than formal ward rounds, 17 passively accepted their records on rounds but did not ask for them at other times, and one refused to see her record when offered it, insisting that she be told her problems by her doctors. Because of the wide variety of medical problems relative to the small number of subjects (Table 1), no conclusions could be drawn regarding the effect of diagnosis on acceptance of the open-record. EFFECT OF AN OPEN-RECORD ON PATIENTS' KNOWLEDGE OF HEALTH PROBLEMS, AFFECTS, AND ATTITUDES TOWARD HEALTH CARE
As an overall indication of retention of information, the ability to recall medical problems and medicines at time of discharge was compared between the control and experimental group (Table 2 ) . Persons in the open-record group listed a mean of 1.4 out of 4.3 ( 2 9 % ) problems at discharge, while those in the control group listed 1.1 out of 4.5 (24% ). These figures were not significantly different. Both groups could recall three quarters of their drugs by name and dose without assistance. Changes between admission and discharge scores of self-assessment of depression, anxiety, and contentment were remarkably similar in the open-record and control groups. The respective scores in the open-record and control groups were - 0 . 6 1 ± 0.37 and - 0 . 6 0 ± 0.36 for depression, 0.08 ± 0.47 and - 0 . 7 3 ± 0.55 for anxiety, and 0.95 ± 0.42 and 1.28 ± 0.37 for contentment. The mean differences in all three categories between the two groups were not significantly different. Comparisons of attitudes toward doctors, nurses, hospitals, medication, illness, and self showed no significant differences between the open-record group and the control group when measured by the Semantic Differential. In all comparisions the value of P was greater than 0.01. OBSERVATIONS
ACCEPTANCE OF AN OPEN-RECORD
INTERACTION
Of the 25 persons in the experimental group who were
Daily
OF
PATIENT-HEALTH
CARE
observations of patient-health
care
PERSONNEL
personnel
Stevens et a/ • Patients and Hospital Records
Downloaded from https://annals.org by Tulane University user on 01/06/2019
475
Table 2. Problems and Medicines Recalled by Patients at Discharge
Problems Open-record Control Medicines Open-record Control
Mean Total Listed by Patient
Mean Total on Record
Percent Recalled by Patients
1.4 1.1
4.8 4.5
29 24
1.6 1.2
2.1 1.6
76 75
interaction around the open record may be summarized in the following generalizations. When appropriate, examples are given. 1. Information exchange appeared to be facilitated in selected instances. A surprising observation was that two persons with chronic disease in which the etiology was poorly understood by the physician, that is, chronic active hepatitis in one instance and systemic lupus erythematosus in the other, expressed the fear that they in fact had cancer, even when such a fear was totally unfounded. The existence of their fears was in both instances not suspected by the physician. Such fears were not detected by the experimental questionnaire, nor were they expressed to the staff physician until the record was reviewed by the patient. Review of the record provided both a focus for discussion and evidence to clarify the diagnoses for the patients. 2. The record was a single constant source of information for the patient on a ward where as many as six doctors and numerous medical students and nurses communicated with the patient or expressed varying opinions within hearing range of the patient. 3. Differences in medical and lay vocabulary were highlighted by discussions that were prompted by review of the record. One corpulent patient was surprised to find "obesity" listed as a diagnosis. She initially objected to its inclusion because she thought that it represented a critical comment about her appearance. Hopefully insight grew out of a discussion of the potential risks of diabetes and coronary artery disease. 4. The open-record provided an opportunity for audit of immediate medical care by the patient. Review of the record permitted the patient's comment on whether the doctor's list of problems were the same problems that were disturbing the patient. A few patients actively contributed to the data base and monitored its accuracy. An example of this was one pregnant woman who noted the incorrect recording of her blood type where, in fact, an Rh incompatibility existed. As a result, passive immunization was achieved by the appropriate administration of antirhesus antibodies at the time of delivery. 5. Physicians frequently claimed that the time required to deal adequately with discussion raised by patients' seeing their own records exceeded the time normally required for discussion when it was more controllable by the physician. Unfortunately, actual measurements of time at bedside were not made prospectively as part of this study. 6. Conditioned roles that doctors and patients employ in relating to each other initially resulted in awkward 476
discussion around the open-record; doctors needed frequent reminders that a particular patient was in the open-record group. 7. Practical communication problems that interfered with patients' understanding their records included medical abbreviations, vocabulary, and individual doctors' handwriting. 8. Most doctors have developed their own individual style of communication with patients that best fits the doctors personality; the introduction of an open-record at the bedside inevitably forced alteration in this style and met varying amounts of resistance. Similarly, it could not be determined to what extent knowledge that the record might be reviewed by the patient affected the content of the record. Discussion
The open problem-oriented record was introduced into the ward routine in a teaching hospital and its acceptance assessed. As might be expected, there were predictable and substantial obstacles encountered in attempting to implement an open hospital record despite the use of a problem-oriented synopsis that presented information to the patient in a concise and organized form. All patients did not greet the opportunity to view their records with enthusiasm. Many were unable to cope with the record for practical reasons such as intelligence, language difficulties, or their infirmity; others did not wish to part with the emotionally protective convention of leaving the interpretation of their illnesses to their doctors. Furthermore, health care personnel did not always alter willingly their traditional approach, which tended to maintain their control of the interview situation. Several authors convincingly have advocated implementation of an open-record in the ambulatory care setting (1, 3, 4 ) . It may be argued, however, that its application in the inpatient setting might worsen anxiety already made high by symptoms, an unfamiliar setting, and new diagnostic and therapeutic procedures. This concern was not borne out by the results of our study. Neither patient's affect nor attitudes toward various aspects of the health care system appeared to be altered measurably. Implementation of the open-record, however, resulted in numerous individual instances not reflected in responses to the questionnaire where the availability of the record facilitated communication between patient and physician. This facilitation seemed to result from both the record itself and from discussion stimulated by the presence and content of the record. The results of this study suggest that the opportunity to review a problem-oriented hospital record might be offered to all patients with a modest level of intelligence and ability to read and that the patients' preferences are appropriate to determine patients' access to their own medical records, provided that health care personnel are aware that what they write may be reviewed by their patients.
Apr//1977 • Annals of Internal Medicine • Volume 86 • Number 4
Downloaded from https://annals.org by Tulane University user on 01/06/2019
ACKNOWLEDGMENTS: The authors thank Ms. Katherine Sanders for suggestions in the design of the study and Dr. Naomi Breslau for review of the paper. Dr. Stevens was Cleveland Fellow
to the Royal Melbourne Hospital. Dr. Mackay is supported by a grant from the National Health and Medical Research Council of Australia. Received 11 June 1976; revision accepted 11 October 1976. • Requests for reprints should be addressed to David P. Stevens, M.D.; University Hospitals; Cleveland, OH 44106. References 1. BJORN JC, CROSS H D : Problem Oriented Practice. Chicago, Modern Hospital Press, 1970 2. HERTZ CG, BERNHEIM JW, PERLOFF TN: Patient participation in
the problem-oriented system: a health care plan. Med Care 14: 77-79, 1976 3. SHENKIN BN, WARNER DC: Giving the patient his medical
record: a proposal to improve the system. N Engl J Med 289: 688-692, 1973 4. BOUCHARD RE, TUFO HM, VAN BUREN HC, et al: The patient
and his problem-oriented
record, in Applying
the Problem-
Oriented System, edited by WALKER HK, HURST JW, WOODY MF.
New York, Medcom Press, 1973, pp. 42-46 5. MOERTEL CG, TAYLOR WF, ROTH A, et al: Who responds to
sugar pills? Mayo Clin Proc 51:96-100, 1976 6. GLEDHILL VX, MACKAY IR, MATHEWS JD, et al: The problem-
oriented medical synopsis. Applications to patient care, education, and research. Ann Intern Med 78:685-691, 1973 7. RAVEN JC: Raven's Progressive Matrices. Melbourne, The Australian Council for Educational Research, 1938 8. OSGOOD CE, SUCI GJ, TANNENBAUM PH: The Measurement of
Meaning. Urbana, University of Illinois Press, 1957
Stevens et a/. • Patients and Hospital Records
Downloaded from https://annals.org by Tulane University user on 01/06/2019
477
