Health reports dictated by healthcare providers are converted into written documents by US based medical transcription companies and include history and physical reports (H&P), progress notes, consultation reports, surgery notes, discharge summaries, and more. As of April 2021, a provision of the 21st Century Cures Act requires healthcare providers to give their patients free access to their electronic medical record chart notes.
The United States Core Data for Interoperability (USCDI) lists 8 types of clinical notes that must be shared:
- Consultation Notes
- Discharge Summary Notes
- Imaging Narratives
- Laboratory Report Narratives
- Pathology Report Narratives
- Procedure Notes
- Progress Notes
Studies have found that “shared visit notes” improve patient-provider communication and enhance the quality and safety of health care. According to the OpenNotes initiative, patient-reported benefits of reading their visit notes include:
- Better understanding of their health and medical conditions
- Can remember their treatment plan more correctly
- Are better prepared for visits
- Experience more control over their care
- Take better care of themselves
- Better medication adherence
- More involvement in their own health and care through proactive conversations with their clinicians
Sharing notes also improve medical record accuracy as patients can alert their physician if they notice errors in the notes. Studies also report that open and honest communication can help decrease litigation risks. It can also reduce caregiver anxiety and stress allowing them to view the physician’s observations on the patient’s presentation, diagnoses, prognoses and treatments being considered.
Clinician Concerns about Patient Access to Medical Records
The effects of open notes have been studied for years. Earlier, physicians had many concerns about sharing visit notes with patients. One concern is that patients may feel confused or distressed when they read the notes. They would find it difficult to understand complex language, medical jargon, abbreviations, acronyms and pejorative terms in medical notes.
Another concern is about the use of such as ‘obesity’ or ‘overweight’, which patients tend to find offensive. Heather Gantzer, an internist in Minnesota and recent chair of the board of regents for the American College of Physicians notes that obesity is a “really painful, painful word” for some people (Stat News, June 18, 2021). She opts to use objective terms such as a numerical BMI instead.
Writing more transparent notes can be more challenging if the patient has multiple psychological symptoms without organic disease, or in a malingering patient, notes David Blumenthal, MD in an article in The Rheumatologist. Physicians are also pondering about issues such as maintaining privacy for teenagers when their parents can access their notes. Moreover, if patients can see their test results before hearing about it from their doctor, it can end up being very distressing for them.
So how can clinicians overcome these concerns with open notes becoming the rule? Here are some expert recommendations that can help physicians successfully manage the transition to open notes:
- Ensure Clear and Organized Notes: While the new law requires providing patients with timely access to notes and test results, it does not require that clinicians change their writing. However, physicians need to focus on creating patient-friendly notes that help patients find important information, and promote patient education and engagement. Being brief and using direct, simple language with less abbreviations or medical jargon, can avoid confusion for patients and for other physicians. Medical terms can be explained briefly, where necessary. Using a conversational style can help when in doubt (www.medscape.com).
- Avoid Subjective Comments: Physicians need ensure accurate and objective in their reporting. This also means avoiding labels and using descriptive words. Subjective comments can lead other physicians or anyone else reading the notes to form an opinion of their own, which may not be correct. The goal should be to create a candid note that tells the reader exactly what is going on with the patient.
- Use Language that Drives Positive Changes: Physicians need to focus on writing the medical record in a way that encourages patients to make positive changes, just as they would do in conversations during the office visit. Being less critical, avoiding bias, and showing appreciation for the patient’s accomplishments in one way of doing this. Providing a clear follow-up plan can prove reassuring for patients who are overwhelmed or feel worried.
- Make Patient Portals Easier to Use: It would also be helpful to patients if existing portals are made easier to use. Mobile patient portals can improve the level of engagement for patients who may prefer to access their notes and manage their health using a smartphone and other mobile device. Creating platforms that link to educational materials and trusted content can help patients understand their medical record/condition more easily.
- Encourage Patients to Read their Medical Notes: When patients, families and caregivers review notes, they may be encouraged to ask for clarifications and follow mutually agreed-upon treatment plans. This can also help them identify clinically important inaccuracies, which can be corrected or edited by the provider using the right mechanisms. According to Liz Salmi, senior strategist at OpenNotes, patients who have serious or chronic conditions are more likely to read their notes (www.medscape.com). As they are technically savvy, younger patients are also more likely to read their medical notes. It is believed that patients who are less educated, and have poor health literacy and poorer self-reported health are not likely to view their notes.
- Know Information Blocking Exceptions: Exceptions to the Interoperability and Information Blocking Rule allow providers to block information in the patient portal in certain complex situations. Also, the rules do not apply to psychotherapy notes that a mental health professional records for documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session.
With Open Notes, physicians need to ensure accurate records that improve patient safety. Partnering with an experienced medical transcription company is the best way to do this and ease the EHR documentation task.