This study by Vanka, et al, presents 10 guidelines for patient-centered medical documentation, emphasizing respect, clarity, and inclusivity in clinical notes. These principles aim to empower patients, improve trust, and enhance medical education on open notes practices.
Clinician Views/Experiences
Clinician and patient perspectives on the exchange of sensitive social determinants of health information
The findings of this study suggest that a multifaceted approach, taking both patients’ and clinicians’ concerns and preferences into account, is needed to improve the collection, documentation, and exchange of SDOH data to benefit both direct patient care and broader efforts at improving public health.
When bad news comes through the portal: Strengthening trust and guiding patients when they receive bad results before their clinicians
In this chapter, perspectives from a patient with cancer, an oncologist, and a cancer psychiatrist (in that order) are shared to illuminate the adjustments made in clinician-patient communication amid the era of nearly instantaneous results within the electronic health record.
Psychiatrists’ perceptions of conditions and consequences associated with the implementation of open notes: Qualitative investigation
Psychiatrists practiced in Germany where open notes have not yet been established as part of the healthcare data infrastructure. Open notes were perceived to increase transparency and patient involvement but were also believed to raise issues of stigmatization and conflicts.
A patient-centered documentation skills curriculum for preclerkship medical students in an open notes era
We developed this session for first-year medical students within their foundational clinical skills course to place bias-free language at the forefront of how they learn to construct a medical note. While the longitudinal impact remains to be seen, it is clear patient-centered documentation skills should be an integral part of documentation education.
Adolescent access to clinicians’ notes: Adolescent, parent, and clinician perspectives
This study aims to identify adolescent, parent, and clinician perspectives on the anticipated benefits and concerns of giving adolescents access to clinicians’ notes and strategies to support note-sharing in this population. These strategies may reinforce the potential benefits and mitigate the challenges of sharing notes with adolescent patients.
Co-designing an initiative to increase shared access to older adults’ patient portals: Stakeholder engagement
We partnered with 3 health care organizations to co-design an initiative that aimed to increase shared access registration and use and that can be implemented using existing patient portals. Educational materials are publicly available at Coalition for Care Partners.
Patient online record access in English primary care: Qualitative survey study of general practitioners’ views
This study provides timely information on the views of GPs in England regarding patient access to their web-based health records. Overwhelmingly, GPs were skeptical about the benefits of access both for patients and to their practices.
Understanding the Cures Act Information Blocking Rule in cancer care: A mixed methods exploration of patient and clinician perspectives and recommendations for policy makers
Patients with cancer and their cancer care teams want the ability to tailor information release based on individual preferences and goals. Understanding how to tailor implementation of the Information Blocking Rule is essential for retaining its benefits and minimizing unintended harm for patients with cancer.
A patient-centered approach to writing ambulatory visit notes in the Cures Act era
Most note-writing guides to date have focused on the experience of clinicians. Here, we build on these tips by integrating patient perspectives related to note-reading.
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