Help |
Site Map
|
Be Clear and Succinct
Clear and organized notes allow patients to identify key information, facilitating patient education and engagement. Brevity improves readability and speeds up documentation. Direct and simple language, with minimal abbreviations or medical jargon, helps prevent confusion for patients and for other doctors.
Directly and Respectfully Address Concerns
While doctors have long struggled with recording sensitive issues, a good rule of thumb is to discuss what you write, and write what you discuss.
Candid wording and clearly written follow-up plans may allay fears among anxious patients who otherwise might feel overwhelmed or assume the worst possible scenario. Seeing a diagnosis codified in the note can feel more tangible to patients, and using frank but caring written words might help overcome denial, de-stigmatize a condition, or even motivate behavior change.
,
,
,
Patients concerned that legally, financially, or socially sensitive information discussed during a visit will be added to the medical record might ask to have this information omitted. Patients should be reassured about the protections provided by federal law, including the Health Insurance Portability and Accountability Act (HIPAA) and 42 CFR part 2.
,
Documenting general statements about sensitive topics without elaborating on potentially humiliating details is a strategy that can allay patients' apprehension.
Many electronic health record systems allow doctors to shield specific notes or parts of the record from the patient portal. This can be helpful in the uncommon instance when a doctor determines that reading a note may harm a patient. However, with rare exceptions, HIPAA gives patients the right to access notes,
so doctors who withhold a note from online viewing should discuss this with the patient beforehand.
Use Supportive Language
Rather than focusing exclusively on problems, the medical record can also underscore patient accomplishments, thereby encouraging and empowering patients to make positive changes.
Doctors often focus on positive change during conversations as a way of motivating patients, but including similar statements in visit notes adds a new dimension to the care we provide. Similarly, utilizing descriptive (rather than labeling) words can result in more objective, less judgmental notes.
,
Although it is not feasible to eliminate all potentially offensive terms, doctors who write notes while remembering that patients can read them may avoid obviously problematic words or abbreviations.
Include Patients in the Note-writing Process
Some doctors dictate, type, or review notes with patients during the office visit. Simply turning the computer screen toward the patient takes advantage of natural opportunities to check patient comprehension. Such approaches help patients understand how notes are generated and can save doctors time by completing portions of the documentation during the course of the visit. Some practices ask patients to type their agenda into the medical record prior to meeting as a way of prioritizing patient concerns and encouraging reflection on visit goals.
,
Moving forward, patients will upload data to their medical record from myriad electronic health applications.
By actively involving patients in documenting their clinic visits, doctors could help patients organize, interpret, and prioritize this deluge of information.
Encourage All Patients to Read Their Notes
We suggest that all patients should be invited to join portals, review their notes, seek clarification, and act on mutually agreed-upon plans. Each are crucial steps for helping patients to realize benefits from reading visit notes. Electronic systems that notify patients when notes are available can substantially increase reading rates.
By personal preference, some patients will choose not to read their doctors' notes. This may be particularly true for patients with less education, poorer self-reported health, and poor health literacy.
Involving family, friends, or health navigators in the dissemination of notes should be considered, but further research and innovation is needed to encourage all patients to examine the benefits of viewing notes.
Ask for and Utilize Feedback
Requesting patient feedback to clarify potential misunderstandings may better inform the doctor about the patient's level of understanding of her health and the care plan. Encouraging patients to reflect on the visit afterward may uncover missed information, improve mutual understanding, and strengthen a sense of partnership.
Thus, in addition to improving patient–doctor rapport, this type of feedback has important patient safety implications.
Be Familiar with How to Amend Notes
Although experience to date suggests that remarkably few patients request changes,
doctors should be familiar with the note amendment process within their own practice setting. Not all requests for amendments must be accommodated. For example, helping patients distinguish between factual inaccuracies (appropriate to amend) and clinical judgment (amended at the doctor's discretion) sets expectations for patients. More substantial or adversarial addenda should follow practice policies governing modifications of the medical record. Often, patients may submit their own statement through a formal amendment request.
Conclusion
While medical records will continue to serve a central role for doctors, they can also be a powerful tool for patients.
,
Substantially more experience and evidence is needed to further guide the content and format of clinical notes and the entire electronic health record. Although the thought of adding yet another dimension to our notes likely induces anxiety (if not ire!) for many doctors, we hope our suggestions will stimulate discussion about this topic. We encourage doctors to share their collective experience and insight as we move into a new era of fully transparent medical records.
-
OpenNotes. More than 6 million patients have easy access to their clinicians' notes. 2016, Available at: http://www.opennotes.org/wp-content/uploads/2012/08/opennotes_map_2.10.2016-copy.jpg. Accessed April 2, 2016.
-
- Delbanco T.
- Walker J.
- Bell S.K.
- et al.
Inviting patients to read their doctors' notes: a quasi-experimental study and a look ahead.
Ann Intern Med. 2012; 157: 461-470
-
- Nazi K.M.
- Turvey C.L.
- Klein D.M.
- et al.
VA OpenNotes: exploring the experiences of early patient adopters with access to clinical notes.
J Am Med Inform Assoc. 2015; 22: 380-389
-
Patients' memory for medical information.
J R Soc Med. 2003; 96: 219-222
-
A piece of my mind. I'm sorry.
JAMA. 2015; 313: 2427-2428
-
- Kahn M.W.
- Bell S.K.
- Walker J.
- Delbanco T.
A piece of my mind. Let's show patients their mental health records.
JAMA. 2014; 311: 1291-1292
-
OpenNotes. Writing fully transparent notes. 2014, Available at: http://www.opennotes.org/toolkit/writing-fully-transparent-notes/. Accessed April 2, 2016.
-
Caffrey M. Rule says hospitals, providers must give patients access to records. 2016, Available at: http://www.ajmc.com/focus-of-the-week/0116/rule-says-hospitals-providers-must-give-patients-access-to-records?utm_source=Informz&utm_medium=AJMC&utm_campaign=MC_Minute_Results_1-23-16. Accessed February 4, 2016.
-
US Department of Health and Human Services. Health Insurance Portability and Accountability Act of 1996. 1996, Available at: https://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/HIPAAGenInfo/TheHIPAALawandRelated-Information.html. Accessed April 2, 2016.
-
US Department of Health and Human Services. Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2. (1987). Available at: http://www.ecfr.gov/cgi-bin/text-idx?rgn=div5;node=42%3A1.0.1.1.2. Accessed June 22, 2016.
Pages: 1 · 2 · 3 · 4 · 5
Relationships and Going Places, Health, Fitness and Style, News and Issues, Culture Watch, Health and Science, Health Links, Learning, Senior Women Web, Articles, Sightings, What's New
|
|