S Notzon1. 1. Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinik Münster, Albert-Schweitzer-Campus 1, Gebäude A9, 48149, Münster, Deutschland, swantje.notzon@ukmuenster.de.
Abstract
BACKGROUND: In medical ethics there is broad agreement that patients should be empowered to make autonomous decisions about their health and that objective, detailed information promotes these decisions. According to German law patients have a right of access to their own medical records. OBJECTIVES: Which advantages and disadvantages does the access to records have for doctors and patients in psychiatry? Which requirements should be met to make access reasonable for patients? MATERIAL AND METHODS: This article presents an analysis of the legal situation and the state of research, evaluation of empirical studies, discussion of features of psychiatry, its language and patients as well as their influence on access to medical records. RESULTS: Psychiatrists are sometimes concerned about patient access to medical records and some psychiatric patients feel upset or uncomfortable after having inspected their records. The misunderstanding and stigmatization of psychiatric terms, the vulnerability of psychiatric patients and the nature of psychiatric disorders, the description of which affects fundamental aspects of personality, all play a role in this. In addition, in having access to their records patients use a source of information that was originally written for other addressees. Information content and language are not adapted to their needs. Possible solutions could involve improvements in patient education and (stylistic) changes in writing records.
BACKGROUND: In medical ethics there is broad agreement that patients should be empowered to make autonomous decisions about their health and that objective, detailed information promotes these decisions. According to German law patients have a right of access to their own medical records. OBJECTIVES: Which advantages and disadvantages does the access to records have for doctors and patients in psychiatry? Which requirements should be met to make access reasonable for patients? MATERIAL AND METHODS: This article presents an analysis of the legal situation and the state of research, evaluation of empirical studies, discussion of features of psychiatry, its language and patients as well as their influence on access to medical records. RESULTS: Psychiatrists are sometimes concerned about patient access to medical records and some psychiatricpatients feel upset or uncomfortable after having inspected their records. The misunderstanding and stigmatization of psychiatric terms, the vulnerability of psychiatricpatients and the nature of psychiatric disorders, the description of which affects fundamental aspects of personality, all play a role in this. In addition, in having access to their records patients use a source of information that was originally written for other addressees. Information content and language are not adapted to their needs. Possible solutions could involve improvements in patient education and (stylistic) changes in writing records.