Year: 2025
Type: article
Abstract: Background: Patients in mental health care can read their medical records in an online portal. Research based on interviews and surveys shows that this opportunity presents new challenges for healthcare personnel when writing medical records. This study examined what characterised the genre in the early phase of outpatient treatment. We aimed to formulate concepts that may raise awareness of the medical record genre and promote reflection on different ways of keeping medical records. Method: An interdisciplinary research group analysed text from six medical records from the first three months of treatment in outpatient mental health care. Results: The analysis resulted in four main categories: 1) professional authority in the text, 2) patient perspective in the text, 3) standardised text and 4) incoherent text. Subcategories nuanced the findings. Implications: We used the findings to consider how medical record writing can enhance the therapeutic relationship: healthcare personnel will be able to develop their repertoire in the direction of change-oriented records by expressing professional authority from more function- and participant-oriented perspectives, using experiential language and individualising standardised text to reduce text fragmentation. In this way, medical records may balance patient participation with a distinctly situation-based professional assessment. Keywords: electronic health record, mental health, medical record genre, text analysis, open notes
DOI: 10.52734/kytl2024
Language: English
Subfield: Health Information Management
Field: Health Professions
Domain: Health Sciences
Open Access status: diamond
Funder: Universitetet i Oslo
OpenAlex ID: W4409767936