Patients will soon have expanded rights to read your clinical notes: how to make them patient friendly

Update: On Oct. 29, the U.S. Department of Health and Human Services Office of the National Coordinator for Health IT released an interim final rule that delays the information blocking rules until April 2021.

On Nov. 2, the 21st Century Cures Act goes into effect, giving patients the right to immediate electronic access to their health records. This includes not only test results, medication lists, and referral information, but also physicians’ notes.

Although the new law does not require physicians to change their note-writing style, some small modifications can be helpful, particularly when documenting potentially sensitive topics such as mental health, obesity, substance use disorder, sexual history, or spousal abuse.

Here are four tips for writing patient-friendly notes in an “open notes” world.

1. Be transparent. Your communication with the patient in the office should reflect what you put in the note. There should be no surprises.

2. Minimize jargon and abbreviations. If there are medical terms that patients might easily misinterpret, briefly define or simplify them, such as “short of breath,” rather than SOB or dyspneic.

3. Highlight the patient's strengths and achievements in addition to the patient’s problems. This can be particularly helpful for patients with mental health issues because it gives them a more balanced perspective of their illness as they tackle difficult behavioral changes.

4. Describe behaviors rather than labeling the patient or making judgments. For example, consider these alternatives:

• “Patient could not recall” instead of “Poor historian,”
• “Patient is not doing X” instead of “Non-compliant,”
• “Patient prefers not to” or “Patient declines” instead of “Patient refuses.”

Read the full FPM article: “Sharing Visit Notes: Getting Patients and Physicians on the Same Page.”