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/
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