Clinical documentation of patient identities in the electronic health record: Ethical principles to consider.

IF 1.9 3区 心理学 Q3 PSYCHOLOGY, CLINICAL
Psychological Services Pub Date : 2024-08-01 Epub Date: 2023-11-02 DOI:10.1037/ser0000816
Suzanne E Decker, Minnah W Farook, Sarah Meshberg-Cohen, Taiki Matsuura, Maggie Manning, Erica A Abel, Laura Blakley, Faith Prelli
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引用次数: 0

Abstract

The American Psychological Association's multicultural guidelines encourage psychologists to use language sensitive to the lived experiences of the individuals they serve. In organized care settings, psychologists have important decisions to make about the language they use in the electronic health record (EHR), which may be accessible to both the patient and other health care providers. Language about patient identities (including but not limited to race, ethnicity, gender, and sexual orientation) is especially important, but little guidance exists for psychologists on how and when to document these identities in the EHR. Moreover, organizational mandates, patient preferences, fluid identities, and shifting language may suggest different documentation approaches, posing ethical dilemmas for psychologists to navigate. In this article, we review the purposes of documentation in organized care settings, review how each of the five American Psychological Association Code of Ethics' General Principles relates to identity language in EHR documentation, and propose a set of questions for psychologists to ask themselves and their patients when making choices about documenting identity variables in the EHR. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

电子健康记录中患者身份的临床文档:需要考虑的伦理原则。
美国心理协会的多元文化指导方针鼓励心理学家使用对他们所服务的个人的生活经历敏感的语言。在有组织的护理环境中,心理学家需要对他们在电子健康记录(EHR)中使用的语言做出重要决定,患者和其他医疗保健提供者都可以访问电子健康记录。关于患者身份(包括但不限于种族、民族、性别和性取向)的语言尤其重要,但心理学家几乎没有关于如何以及何时在EHR中记录这些身份的指导。此外,组织任务、患者偏好、流动的身份和不断变化的语言可能会提出不同的记录方法,给心理学家带来道德困境。在这篇文章中,我们回顾了在有组织的护理环境中进行记录的目的,回顾了五项美国心理协会道德准则的一般原则中的每一项与EHR文件中的身份语言的关系,并提出了一系列问题,供心理学家在选择在EHR中记录身份变量时问自己和患者。(PsycInfo数据库记录(c)2023 APA,保留所有权利)。
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来源期刊
Psychological Services
Psychological Services PSYCHOLOGY, CLINICAL-
CiteScore
4.20
自引率
13.00%
发文量
216
期刊介绍: Psychological Services publishes high-quality data-based articles on the broad range of psychological services. While the Division"s focus is on psychologists in "public service," usually defined as being employed by a governmental agency, Psychological Services covers the full range of psychological services provided in any service delivery setting. Psychological Services encourages submission of papers that focus on broad issues related to psychotherapy outcomes, evaluations of psychological service programs and systems, and public policy analyses.
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