What Your Clinical Notes May Reveal to Patients
It’s been a few months since a federal mandate called the 21st Century Cures Act began requiring that hospitals would give patients immediate electronic access to “open notes” such as consultations, discharge summaries, physical examinations, laboratory and pathology report narratives, as well as notes on procedures and progress. As clinicians everywhere have begun adjusting to the new normal of delivering seamless and secure electronic health information, it is a good time to evaluate the quality of these types of notes from the viewpoint of the provider.
Your Delivery of Personal Health Information
With the option of quick dissemination of personal health information, it is important to take proper care when drafting your inpatient and outpatient notes. Here are a few examples of what could potentially go wrong if not careful:
Potential challenge # 1: If not given in the proper context, patients can be scared or confused when reading provider notes, even with what you might consider the most ordinary type of message.
Recommended solution: Write clearly and concisely, leaving ambiguity out of your communications. Remember, you are writing for the patient, which can be vastly different than writing for a colleague.
Potential challenge # 2: Patients can jump to quick assumptions if notes are not explained in the right way.
Recommended solution: It is especially important to communicate in layman’s terms to avoid a misunderstanding. Always read over your notes before sending, and picture reading them to a person with little to no medical background.
Potential challenge# 3: Words such as cancer, tumor, and diagnosis, as well as certain test results often have extremely negative connotations associated with them and can send a patient straight into panic if they don’t know what they are looking at.
Recommended solution: Leave these words out of your report until you have spoken with the patient at length. You will want to be sure to review and explain any new findings before sending off any notes for them to review on their own.
General “Open Note” Provisions
A good rule of thumb to follow is to discuss all health concerns, possibilities, and next steps with the patient each time you see them. This way, if your clinical notes end up in your patient’s hands before you have had the opportunity to see them again next, your initial communication will put them at ease with any message they will be reading in the future. This type of pre-counseling can help stop potential issues before they arise. The best possible scenario is to be with the patient as they receive their clinical notes to address any questions. While we know this is unlikely in most circumstances due to demanding schedules, it is something to strive toward. Being able to sit with a patient, even to explain another physician’s notes, can help alleviate stress and medical insecurities.
Although it is understood that many hospitalists may feel nervous about this new type of medical prose, patients seemingly enjoy the ease of access to their personal health information. It is important to remember that going just a little out of your way to communicate effectively can do wonders for boosting a patient’s morale and confidence. By giving patients more direct access into their medical records, it can help reassure them that they are getting the best care, and most importantly, that you, the hospitalist has their best interest at heart.
As communication methods become more readily available as a two-way street between patients and providers, it’s important to remain informed, understanding and open-minded to positive change.
Contact Advanced Care Hospitalists to Learn More
ACH is a Lakeland-based hospitalist group providing comprehensive patient care in community hospitals across Central Florida. If you are interested in learning more about our programs, services, providers or becoming a partner facility, please call us at 863-816-5884 or fill out a contact form online.