How to write an Open Note for patients

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2017-0904OpenNotesDocuTipsCTLin.pdf

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.

In short:

  1. 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.
  2. 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”.
  3. It gets easier with practice.
  4. 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.

Author: CT Lin

CMIO, University of Colorado Health; Professor, University of Colorado School of Medicine

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