OpenNotes Helps Physicians Work on Writing Better Notes
Although many physicians were initially reluctant to share their notes with patients, the OpenNotes movement to make clinicians' notes visible to patients through their electronic health records has grown to include 40 million patients. It also has led physicians to reconsider how they write their notes.
During an Oct. 8 webinar, several physicians discussed some research and lessons learned in regard to patient perceptions of notes in terms of what they find valuable or upsetting about reading them.
Jared Klein, M.D., M.P.H., a physician at the Adult Medicine Clinic and medical director of the After Care Clinic at Harborview and a University of Washington assistant professor of General Internal Medicine, offered several tips. He recommended being clear and succinct in documentation. He suggests starting with the Assessment and Plan section and avoid importing excessive data or using jargon that patients may not understand. For instance, write out “Follow Up” rather than “F/U.”
“We recommend directly and respectfully addressing concerns,” Klein said, adding that one phrase they have adopted at UW is “Discuss what you write and write what you discuss.” He said it is especially important to discuss with patients notes about obesity, substance use, mental health, or intimate partner violence.
Another suggestion is to use supportive language, both for written and verbal communication. “We have to retrain ourselves to do it,” he said. Instead of saying “patient refuses,” say “opts out.”
Although it can be challenging, another idea is to include patients in the note-writing process, Klein said. “I try to angle the computer so we can both see. When dictation is available, consider doing it with the patient present and you could invite the patient to contribute, he said.
To get more out of OpenNotes, Klein said, you should encourage patients to read the notes. “You can ask them to look at the note to make sure you are both on the same page and help you get feedback, and then you can ask them if they read the notes and whether they had questions or concerns.” Remind them that you are working together in a treatment team. Ask again if there are any mistakes in the note, he added.
Klein also recommends being prepared to amend notes when an error occurs, such as an injury recorded on the wrong side of the body or to add a sentence stating that patient disagrees with an assessment.
Leonor Fernandez, M.D., an assistant professor of medicine at Beth Israel Deaconess Medical Center in Boston, has done research about what patients might find not so positive from reading notes. She and colleagues surveyed almost 30,000 patients in three health systems: University of Washington, Geisinger and Beth Israel. When they asked if the patients had ever feel offended or judged by a note, one in 10 said yes. Some said the tone of the note was cold or condescending. Others said the physicians weren’t reporting well what they said or didn’t seem to hear what they said. “Some language we use is inherently weird,” Fernandez said. “We say the patient claims x, as though it is a legal document, or the patient refuses or denies; or complains of. It is a strange construction.”
She said there are issues around how physicians write about phrases like obese and anxious. One 60-year-old patient was insulted that a young doctor referred to her as elderly in his note. Fernandez said it is important to talk to patients about any new diagnosis. Patients say they want their perspective documented, particularly when they disagree with the doctor. “They want to be respected by having their perspective recorded,” she said, adding that physicians don’t have to change everything about how they work, but this type of feedback can guide them when thinking about the vocabulary and idioms they use.
