https://www.infirmiere-canadienne.com/blogs/ic-contenu/2025/06/09/trouver-la-voix-des-patients/
How online access to medical documents is an opportunity to add the patient’s perspective
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Advancements of technology offer transformative opportunities for clinical documentation, extending its reach from health-care settings to patients’ homes.
Takeaway messages
- There are no consistent definitions of the patient voice.
- The patient voice is integral to capture in the electronic health record.
- Nurses play an integral role in conceptualizing the patient voice and translating ways to capture it in the electronic health record.
“[A]t the core, when it comes to mental health and well-being, we are all the same – whether we are currently experiencing a mental health problem or illness or not. There is no us and them.” (Mental Health Commission of Canada, 2009, p. 13).
The term “patient voice” is frequently used in mental health care to describe the patient’s perspective. Traditional documentation methods for inpatient mental health services are largely narratives of the nurses’ observations (Myklebust et al., 2018). The rationale for such documentation is thought to support building a comprehensive story of the patient.
Courtesy of Michelle Danda
“With the increasing integration of EHRs, it is time for nurses to challenge the notion that narrative documentation is as useful as traditionally believed for sharing insights about the patient’s perspective,” Michelle Danda says.
The patient story is seen as valuable, a key component of organizing the data about the patient into a chronological description of what the patient and the nurse have done during a nursing shift, an evaluation of any interventions provided, and the plan moving forward.
However, the notion of a nurse-constructed narrative about a patient raises some questions regarding whose story is being shared: is it the patient’s own, or the nurse’s story constructed about the patient? Consideration must be given to how patients can increasingly participate in the clinical documentation process with the increasing use of electronic systems and electronic patient portals that allow collaboration and co-creation of health records (Goedhart et al., 2021).
With design and implementation of electronic health records (EHRs) there is an increased emphasis on standardized, quantifiable, and discrete data. Clinicians, however, have been resistent to adopting EHRs because the data that is collected tends to be impersonal, problem focused, and limited in capturing the unique aspects of patient’s illness experience (Tondora et al., 2021).
Assessment tools — such as mental status exams, suicide screening, and symptoms inventories — have been common in mental health care for decades to counteract the limitations of EHRs (Coombs et al., 2013). Similarly, attempts at documenting objective data have been known to be filtered through the subjective perspective of the clinician observing and documenting, bringing into question the value of narrative reports (Kelly et al., 2023).
With the increasing integration of EHRs, it is time for nurses to challenge the notion that narrative documentation is as useful as traditionally believed for sharing insights about the patient’s perspective. In this article, I will put forth the argument that the underlying motivation to retain narrative documentation is based on outdated notions of what is seen as valuable information to capture in order to demonstrate delivery of competent patient care and communicate and collaborate with the health-care team.
Following this, I will argue that inclusion of the patient perspective must give opportunity for the patient to document their voice, an opportunity that is evermore present with such tools as patient portals and mobile devices (Wazni et al., 2023).
Background
In the realm of health care, the narrative documentation of patient experiences has long been lauded as a cornerstone of comprehensive clinical records. Traditionally, this approach has been rooted in capturing the patient's illness journey and their personal account within the hospital setting. This method aligns with the medical model of clinical documentation, which emphasizes the identification and recording of problems and symptoms (Alex & Whitty-Rogers, 2012).
However, the time has come to critically evaluate whether this narrative approach is indeed the optimal method for documenting nursing care, or whether it might fall short in certain aspects of capturing the full scope of nursing practice.
As health care evolves and the scope of nursing practice expands, there is a growing recognition of the need for documentation practices that reflect nursing paradigms more accurately. This shift calls for a re-evaluation of current documentation methods and the integration of nursing theory into both clinical documentation and EHR design, while also centring the patient voice in a meaningful way.
By aligning documentation practices with nursing theory, nursing care can be better captured and enhance the quality of patient records, leading to improved patient outcomes and more effective interdisciplinary collaboration.
Nursing theory to support changing perspectives
In the context of evolving clinical documentation practices, Rosemarie Rizzo Parse’s human becoming theory offers a crucial lens for re-evaluating nursing practice, particularly in mental health settings. Parse's theory conceptualizes nursing as a dynamic process in which the nurse engages with the patient to facilitate their journey toward a more profound sense of humanity (Parse, 1992).
From this perspective, health is not merely the absence of illness but a continuous process of becoming more fully human, a process in which nurses play a vital role. This framework underscores that nursing extends beyond the mere execution of tasks such as administering medications or conducting mental status exams.
The human becoming theory can allow nurses in mental health settings to see beyond observing and reporting for the purpose of creating notes for the doctor and other allied health clinicians.
Common practice in many inpatient mental health environments involves creating narrative documents that chronicle daily events. However, these narratives are frequently marked by bias, ambiguous language, and judgmental tone (Martin & Ricciardelli, 2022). Such documentation practices are typically grounded in conventional approaches that focus on capturing symptom reduction and responses to treatment, often at the expense of a more comprehensive portrayal of the patient’s experience.
While there are occasional opportunities for patients to contribute their perspectives to their records, they rarely have the chance to review or influence the content of these charts. As a result, the patient’s voice in clinical documentation is often limited to a narrow view of their illness experience, rather than reflecting the holistic and evolving nature of their health journey.
Revisiting Parse’s human becoming theory provides an opportunity to challenge and transform these traditional documentation practices. By aligning clinical documentation with this nursing theory, there is potential to enrich the patient narrative, move beyond a problem-based perspective, and create records that more accurately reflect the patient’s holistic experience. This approach not only enhances the quality of documentation but also supports a more nuanced and compassionate understanding of patient care.
Ethical considerations and innovations in patient portals for mental health records
The advent of online patient portals has revolutionized access to health information, yet it also raises significant ethical questions, particularly concerning mental health records. These questions include whether patients diagnosed with mental illnesses should have the same level of access to their health records as those without such diagnoses, and whether individuals who have interacted with mental health services should have access to all parts of their health records, including those related to mental health encounters (Strudwick et al., 2019). Deep reflection is required to understand the assumptions that underlie the concerns, along with the ethical implications.
Ethical concerns about patient access often revolve around the potential emotional impact of viewing clinical records that include mental health diagnoses. Understanding these concerns requires a thorough examination of the assumptions underlying these fears, as well as their broader ethical implications.
Are clinicians worried that patients might be distressed by their mental health documentation, and if so, why? It is crucial to explore whether these concerns are rooted in the content of mental health documentation itself or in prevailing attitudes toward mental illness.
Historically, patients could access their health records only through complex and privacy-intensive processes. With the introduction of EHRs, there has been a significant enhancement in the ability to capture and share patient information efficiently. This technological progression necessitates a shift in our understanding of the purpose of clinical documentation and its intended audience.
Today, patient portals offer more direct access to health data, including mental health records. The emerging practice of allowing patients to view their mental health documentation prompts a re-evaluation of traditional limitations. Are these limitations driven by concerns about the sensitivity of patient information, or do they reflect a deeper issue related to the stigma surrounding mental illness? It is essential to address whether the restrictions on access are due to outdated documentation practices or are symptomatic of broader misconceptions about individuals with mental health conditions.
Recent advances in technology also introduce the concept of co-production of health data, where patients can contribute their own perspectives on their health, including mood, medication responses, and side effects. This shift toward person-centred care offers new opportunities for integrating patient perspectives into clinical records, challenging traditional views on the subjectivity of mental health data.
Historically, efforts to document mental health data aimed for objectivity, yet such records were inevitably influenced by the perspective of the documenting nurse. This realization underscores the need to reconsider how mental health information is documented and accessed, ensuring that it aligns with contemporary understandings of patient engagement and empowerment.
The future of the patient voice and the EHR
Advancements of technology offer transformative opportunities for clinical documentation, extending its reach from health-care settings to patients’ homes. The concept of co-production — that is, the process of patients actively, collaboratively contributing their own health information — represents a significant shift toward more inclusive and personalized documentation, challenging traditional notions that nurses create the patient narrative.
By enabling patients to provide insights into their mood, medication responses, and side effects, this approach facilitates a more comprehensive integration of the patient’s perspective into their health records. The patient voice is captured, as they contribute to constructing their story. Such innovations support the principles of person-centred and individualized care, which arguably are not achieved if the patient and their family are not actively engaged in documenting their health-care experience.
Parse’s human becoming theory offers valuable guidance in this evolving landscape by emphasizing the importance of engaging with patients to understand their journey toward a fuller sense of humanity. It goes beyond merely documenting symptoms and behaviours. This theoretical framework aligns with the principles of person-centred and individualized care, highlighting the need for patients to document their own health experiences.
Historically, efforts to document patient behaviour have been aimed at objectivity, yet it is becoming evident that this data has always been inherently subjective, shaped by the nurse’s perspective. Moving forward, embracing these new methodologies requires a reassessment of conventional practices and an acknowledgment of the subjective nature of all clinical documentation.
References
Alex, M., & Whitty-Rogers, J. (2012). Time to disable the labels that disable: the power of words in nursing and health care with women, children, and families. Advances in Nursing Science, 35(2), 113. https://doi.org/10.1097/ANS.0b013e31824fe6ae
Coombs, T., Crookes, P., & Curtis, J. (2013). A comprehensive mental health nursing assessment: variability of content in practice. Journal of Psychiatric and Mental Health Nursing, 20(2), 150–155. https://doi.org/10.1111/j.1365-2850.2012.01901.x
Goedhart, N.S., Zuiderent-Jerak, T., Woudstra, J., Broerse, J.E.W., Betten, A.W., & Dedding, C. (2021). Persistent inequitable design and implementation of patient portals for users at the margins. Journal of the American Medical Informatics Association: JAMIA, 28(2), 276–283. https://doi.org/10.1093/jamia/ocaa273
Kelly, P.J.A., Snyder, A.M., Agénor, M., Navalta, C.R., Misquith, C., Rich, J.D., & Hughto, J.M.W. (2023). A scoping review of methodological approaches to detect bias in the electronic health record. Stigma and Health. https://doi.org/10.1037/sah0000497
Martin, K., & Ricciardelli, R. (2022). A qualitative review of what forensic mental health nurses include in their documentation. Canadian Journal of Nursing Research, 54(2), 134–143. https://doi.org/10.1177/08445621211018061
Myklebust, K.K., Bjørkly, S., & Råheim, M. (2018). Nursing documentation in inpatient psychiatry: the relevance of nurse–patient interactions in progress notes. A focus group study with mental health staff. Journal of Clinical Nursing, 27(3–4), e611–e622. https://doi.org/10.1111/jocn.14108
Parse, R.R. (1992). Human becoming: Parse’s theory of nursing. Nursing Science Quarterly, 5(1), 35–42.
Strudwick, G., Yeung, A., & Gratzer, D. (2019). Easy access, difficult consequences? Providing psychiatric patients with access to their health records electronically. Frontiers in Psychiatry, 10, 917. https://doi.org/10.3389/fpsyt.2019.00917
Tondora, J., Stanhope, V., Grieder, D., & Wartenberg, D. (2021). The promise and pitfalls of electronic health records and person-centered care planning. The Journal of Behavioral Health Services & Research, 48(3), 487–496. https://doi.org/10.1007/s11414-020-09743-z
Wazni, L., Gifford, W., Perron, A., & Vandyk, A. (2023). Understanding the physical health problems of people with psychotic disorders using digital storytelling. Issues in Mental Health Nursing, 44(8), 690–701. https://doi.org/10.1080/01612840.2023.2229435
Michelle Danda, RN, PhD, CPMHN(C), graduated from the bachelor of nursing accelerated track program at the University of Calgary in 2008 and recently completed her PhD in doctoral nursing program at the University of Alberta. She is a clinical nurse specialist in Vancouver, B.C., and practised mental health and substance use nursing through the Lower Mainland, B.C.
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