American Journal of Medicine, internal medicine, medicine, health, healthy lifestyles, cancer, heart disease, drugs

Your Patient Is Now Reading Your Note: Opportunities, Problems, and Prospects

doctor writing out a prescription

Patients have unprecedented online access to their medical records. More than 6 million Americans can now read their doctors’ notes via patient portals, and continued rapid growth is likely. Sharing notes with patients may yield important health benefits, including increased patient empowerment and improved medication adherence. Seeing written information, including notes, helps patients remember the plan of care, reinforces patients’ positive behaviors, and strengthens the patient–doctor alliance.

As fully transparent medical records proliferate, many questions remain unanswered (Table 1). Such uncertainties create anxiety and apprehension among doctors at a time when many already feel overwhelmed. In an effort to ease the transition to what we believe will be a widespread and ultimately beneficial practice, we draw on over 5 years of the authors’ clinical experience and conversations with clinicians around the country to offer suggestions for creating notes that can work for all concerned (Table 2).

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.

 

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-Jared W. Klein, MD, MPH, Sara L. Jackson, MD, MPH, Sigall K. Bell, MD, Melissa K. Anselmo, MPH, Jan Walker, RN, MBA, Tom Delbanco, MD, Joann G. Elmore, MD, MPH

This article originally appeared in the October 2016 issue of The American Journal of Medicine.

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