{"title":"Using Patient Quotations in Chart Notes: A Clinical Ethics Perspective.","authors":"Olivia Schuman, Haven Gabrielle Romero","doi":"10.1086/727438","DOIUrl":null,"url":null,"abstract":"<p><p>AbstractPer the OpenNotes directive of the 21st Century Cures Act implemented in 2021, patients and their legally recognized representatives must be able to access the electronic medical record in real time. This is an opportunity for clinical ethicists and other providers to reflect on their charting practices, particularly how and when they quote patients. Although using direct quotations is common because it seems to avoid misinterpretation, it may not always be appropriate. In this article, we discuss some of the risks and benefits of quoting in the context of OpenNotes and provide suggestions for how clinical ethicists can leverage their unique position to help mitigate some of these risks and promote more reflective charting practices among the teams they work with.</p>","PeriodicalId":39646,"journal":{"name":"Journal of Clinical Ethics","volume":"34 4","pages":"352-355"},"PeriodicalIF":0.0000,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Journal of Clinical Ethics","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.1086/727438","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q3","JCRName":"Medicine","Score":null,"Total":0}
引用次数: 0
Abstract
AbstractPer the OpenNotes directive of the 21st Century Cures Act implemented in 2021, patients and their legally recognized representatives must be able to access the electronic medical record in real time. This is an opportunity for clinical ethicists and other providers to reflect on their charting practices, particularly how and when they quote patients. Although using direct quotations is common because it seems to avoid misinterpretation, it may not always be appropriate. In this article, we discuss some of the risks and benefits of quoting in the context of OpenNotes and provide suggestions for how clinical ethicists can leverage their unique position to help mitigate some of these risks and promote more reflective charting practices among the teams they work with.
摘要根据2021年实施的《21世纪治愈法案》(21st Century Cures Act)的OpenNotes指令，患者及其法律认可的代理人必须能够实时访问电子病历。这是临床伦理学家和其他提供者反思他们的图表实践的机会，特别是他们如何以及何时引用患者。虽然使用直接引用很常见，因为它似乎可以避免误解，但它可能并不总是合适的。在本文中，我们讨论了在OpenNotes环境中引用的一些风险和好处，并为临床伦理学家如何利用他们独特的地位来帮助减轻这些风险，并在他们合作的团队中促进更多的反思图表实践提供了建议。
期刊介绍：
The Journal of Clinical Ethics is written for and by physicians, nurses, attorneys, clergy, ethicists, and others whose decisions directly affect patients. More than 70 percent of the articles are authored or co-authored by physicians. JCE is a double-blinded, peer-reviewed journal indexed in PubMed, Current Contents/Social & Behavioral Sciences, the Cumulative Index to Nursing & Allied Health Literature, and other indexes.
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