Tidsskrift for den Norske laegeforening : tidsskrift for praktisk medicin, ny raekke · 2026
The patient's voice and the writer's role in mental health records.
Аннотация на английскомСтатьяНазвание и аннотация: Перевод в очереди
Обработка статьи · этапы, ошибки и управление
Загрузка состояния…
Ошибки и ограничения
История · было → стало
Состояние обновляется каждые 5 секунд, пока блок открыт. Процент показывается только там, где известен объём работы. Пауза останавливает продолжение этапа; текущий запрос к источнику может завершиться.
Aaslestad Petter, Bakke Marion Cecilie Andrade, Ringen Petter Andreas, Hem Erlend
Аннотация
BACKGROUND AND AIM: Over recent decades, formal requirements for medical records have been strengthened, for example through patients' rights of access. However, clinical documentation in mental health services has been criticised for becoming increasingly juridified and for failing to recognise patients as whole persons. The aim of this study was to conduct an exploratory investigation of current record-writing practices in mental health care.
MATERIAL AND METHOD: We reviewed ten medical records from patients discharged from the Adult Inpatient Mental Health Unit at the Clinic for Mental Health and Substance Use Disorder, Oslo, who had at least one previous inpatient admission. The material comprised more than 5500 pages in total. A multidisciplinary research group, consisting of a literary scholar and healthcare personnel, analysed clinicians' notes, observational notes from ward staff recorded during admission, and outpatient records.
RESULTS: The records contained overwhelming volumes of text, with extensive verbatim repetition resulting from copy-and-paste practices, which at times obscured inconsistencies and contradictions. New information could appear suddenly and disappear again without reflection. The texts often displayed an inherent unreliability, with contradictory statements appearing side by side. Considerable emphasis was placed on diagnosis and discharge, while reflective discussion of clinical processes was often absent.
INTERPRETATION: Authors of medical records must balance medical, legal and patient-centred requirements. Artificial intelligence is increasingly being introduced into clinical documentation, with the potential to fundamentally alter practice. However, there is also a need for authors to reclaim ownership of the medical record. In this study, the patient record emerges as a document that often exposes the author's sense of powerlessness.
MATERIAL AND METHOD: We reviewed ten medical records from patients discharged from the Adult Inpatient Mental Health Unit at the Clinic for Mental Health and Substance Use Disorder, Oslo, who had at least one previous inpatient admission. The material comprised more than 5500 pages in total. A multidisciplinary research group, consisting of a literary scholar and healthcare personnel, analysed clinicians' notes, observational notes from ward staff recorded during admission, and outpatient records.
RESULTS: The records contained overwhelming volumes of text, with extensive verbatim repetition resulting from copy-and-paste practices, which at times obscured inconsistencies and contradictions. New information could appear suddenly and disappear again without reflection. The texts often displayed an inherent unreliability, with contradictory statements appearing side by side. Considerable emphasis was placed on diagnosis and discharge, while reflective discussion of clinical processes was often absent.
INTERPRETATION: Authors of medical records must balance medical, legal and patient-centred requirements. Artificial intelligence is increasingly being introduced into clinical documentation, with the potential to fundamentally alter practice. However, there is also a need for authors to reclaim ownership of the medical record. In this study, the patient record emerges as a document that often exposes the author's sense of powerlessness.