How to write an open note for patients: 2020 edition

October 30, 2020

By CT Lin, MD

DENVER, CO – I am often asked, “What is the best way to participate in open notes and sharing physician progress notes with patients?”

To answer this question, I created this one-page PDF guide. Feel free to use and share it—and please include attribution when you share.

In Short: 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.

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”
• “patient is non-adherent” instead of “patient refuses”

It gets easier with practice.

I love the quote from Cassandra Cook, PhD. To paraphrase:

If we write things that might offend patients, consider if such writing affects our own attitudes and behavior.

Furthermore, the OpenNotes website has a great toolkit for organizations looking to make the leap. Check out the Implementation Toolkit for healthcare providers.

The CMIO’s Take?

Let’s 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.

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CT Lin, MD, is a practicing physician and Chief Medical Information Officer for University of Colorado Health. Follow him on Twitter at @ctlin1.

This post is re-blogged with permission from The Undiscovered Country, the personal blog of CT Lin, MD.