Having been asked a number of times: what is the best way to participate in open notes and sharing physician progress notes with patients? Attached is our one-page PDF guide. Feel free to use and share. Please do include attribution when you share.
- Don’t Panic! Despite physician fears, patients are not looking for a completely rewritten layperson-friendly note. Many patients find it useful just to have access and be able to show that note to their next healthcare provider. You DON’T have to change a thing.
- The handful of “gotcha” topics in physician progress notes are few, and not difficult to write in a way that is respectful and still accurate. For example, use “shortness of breath” instead of “SOB”; “BMI>30” or “overweight per medical criteria” instead of “morbidly obese”; and “patient is non-adherent” instead of “patient refuses”.
- It gets easier with practice.
- I love the quote from Cassandra Cook. To paraphrase: If we write things that might offend patients, consider if such writing affects our own attitudes and behavior.
Furthermore, the OpenNotes.org website has a great toolkit for organizations looking to make the leap: https://www.opennotes.org/tools-resources/for-health-care-providers/implementation-toolkit/
CMIO’s take? Lets push open notes until it is the default standard for Electronic Health Records and Personal Health Records everywhere. Is your organization on board with open notes? Let me know.