Opening up your Clinical Notes

 Do you want to open up EHR clinical notes to the entire care team - including patients? Some great lessons learned from the Open Notes project 

Clinicians: Writing Notes

Most doctors in the OpenNotes study found that they didn’t need to change dramatically  how they write their notes.  Patients are smart. If they read something they don’t understand, they often look it up, or ask about it.  But, if you are a clinician who wants make your notes as effective as possible to read, try to:

• Avoid jargon and abbreviations
• Briefly define medical terms
• Spell out acronyms, especially ones that might easily be misread (i.e. “SOB,” shortness of breath)
• Before you sign your note, incorporate test results to give patients the full picture
• Encourage patients to ask questions about what they’ve read
• Include educational materials or links to content that can help patients learn more about their medical condition
• Talk about your notes.  Investing a few minutes at an appointment can strengthen the connection between patients and providers.  It can also encourage patients to reveal information they might otherwise be reluctant to bring forth, and allow providers to gauge the level of understanding or opportunities for education.

Patients: Reading Notes

By reading your doctor’s notes, you are taking an important step toward taking responsibility, whether you are healthy or dealing with illness.  Think of these notes as a tool. Patients, providers and caregivers can all use the note as the basis for an agreed-upon care plan. To get the most out of your notes:

• Review them immediately after your appointment, while the conversation is still fresh in your mind. Talk to your doctor if you see anything that you feel is inaccurate.
• Use the notes to check that you are following your agreed upon treatment plan, whether there are any changes to your medications, and which follow up tests or appointments you need to schedule or attend.
• Share them with your family members, caregivers, or others involved in your care and discuss how you are going to work together to make any recommended treatment work.
• Re-read the notes before your next appointment to remind yourself of what you discussed with your health care provider at your last appointment. Think about any improvements you made since your last visit and any new problems you are experiencing since your last visit.  You can also prepare a list of questions based on your note that you want to ask at your next visit.
• Look up health information on the U.S. Department of Health and Human Services Healthfinder website—a great resource for patients.
  
  http://www.myopennotes.org/getting-started/getting-started/