The patient and practitioner as co-authors of the medical record

Abstract

Health care professionals traditionally have resisted patient access to medical records. There is evidence, however, that the patient's medical record can promote improved communication between patient and practitioner. In an exploratory study, patients in a primary care office practice collaborated with their health care professionals in the authorship of their records. Co-authorship was effective in conveying more complete, accurate, and mutually understandable information. The patient-held copy of the record served as an adjunct to this collaborative process. The potential problems and prospects arising from this strategy are discussed.