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Arch Phys Med Rehabil. 1976 Feb;57(2):78-81.

The right to know: giving the patient his medical record.


Each patient admitted to the 16-bed Rehabilitation Medicine Service at Medical Center Hospital of Vermont since October 1972 has received a carbon copy of his full Admission and Discharge notes, containing the complete problem list, and for each problem the relevant data, the Assessment and the Plans. The objectives were to improve patient education; to improve the patient's chances to contribute to the planning of his care; and to increase the staff's accountability to the patient. Over a period of seven months, we evaluated the effect of this maneuver for 125 consecutive patients by means of (1) a report on the patient's reactions, completed by a nurse after she reviewed the record with the patient; (2) a report by the physician stating whether he had expurgated the record for patient use, and recording his observations of patient and family reaction; (3) a questionnaire mailed to patients after discharge. Results indicated that patients were generally comfortable about reading the record, found it educational and appreciated the trust implied. No substantial difficulties arose. Few records were expurgated. The staff has accepted this style as crucial to an appropriate sharing of responsibility between themselves and the patients. We conclude that giving the patient his record is a safe and inexpensive aid to the rehabilitation process, and is probably mandated by the changing relationships between professionals and their clients, and by the patient's need to negotiate his own health care in an increasingly complex and mobile society.

[Indexed for MEDLINE]

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