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.
Health Policy
21st Century Cures Act ONC Rule: Implications for adolescent care and confidentiality protections
This article reviews the key aspects of confidentiality protections in adolescent health care, explains the ONC Rule, outlines clinical, HIT, and equity challenges associated with its implementation, encourages the development of policies protecting the confidentiality of adolescents’ EHI [ … ] and offers tools for analyzing key questions in individual cases and practical steps to address the confidentiality of EHI with patients and parents.
Clinical ethics consultation documentation in the era of open notes
The new regulatory requirements of the 21st Century Cures Act provide a valuable opportunity to involve patients more actively in the documentation and telling of their own story of ethical complexity. Healthcare systems should take advantage of this new era and use open notes as a way to improve CECs documentation and, ultimately, patient care.
Experiences with information blocking in the United States: A national survey of hospitals
We sought to describe hospital leaders’ perceptions of the prevalence of practices that may constitute information blocking, by actor and hospital characteristics, following the rule’s applicability date. These results […] support the need for continued observation to provide a sense of the prevalence of information blocking practices and for education and awareness of information blocking regulations.
Patient access to full general practice health records
Researchers in the UK say patients have little choice but to be more self-reliant due to overwhelming demands on the health system. Ready online access to full health records could help and may also reduce demand.
Sharing Clinical Notes Potential Medical-Legal Benefits and Risks
It is possible that greater mutual understanding and strengthened patient-physician communication could promote better health outcomes and reduce patients’ inclination to litigate even when medical errors do arise. Verifying the potential effects of sharing clinical notes on malpractice liability risks will require thorough study and monitoring.
Open Notes Become Law: A Challenge for Mental Health Practice
Although benefits to patients’ having access to psychiatric notes have been documented, early studies involved patients’ access to hard copies they often reviewed in the presence of mental health professionals. … Clinicians worry about possible harms, and in surveys, many psychiatrists anticipate that patients will become confused, get angry, or decompensate when reading their notes. However, experience challenges the assumption that mental health notes should remain segregated because these patients “cannot handle it.” … Both anecdotally and in surveys, fears among clinicians have largely been unrealized, and we are not aware of any reports of harm to or legal action from patients accessing their mental health notes.
Preparing Patients and Clinicians for Open Notes in Mental Health: Qualitative Inquiry of International Experts
This study provides timely information on policy and training recommendations derived from a wide range of international experts on how to prepare clinicians and patients for open notes in mental health. The results of this study point to the need for further refinement of exemption policies in relation to sharing mental health notes, guidance for patients, and curricular changes for students and clinicians as well as improvements aimed at enhancing patient and clinician-friendly portal design.
How Sharing Clinical Notes Affects the Patient-Physician Relationship
Tom Delbanco, MD, will never forget his “aha!” moment, even though it was nearly 50 years ago.
The patient sitting across from him had been referred to Delbanco for evaluation of hypertension. But Delbanco thought the man’s symptoms suggested he consumed more alcohol than he’d acknowledged.
Delbanco considered adding alcohol misuse to the patient’s “problems list,” but he stopped writing after realizing that the patient, a printer who set type by hand, was reading his notes upside down. Delbanco explained why he had stopped writing and informed the patient that he suspected he drank more than 2 beers a day. If that was the case, Delbanco added, it should be noted on his chart.
Patient Access to Mental Health Notes: Motivating Evidence-Informed Ethical Guidelines
In the last decade, many health organizations have embarked on a revolution in clinical communication. Using electronic devices, patients can now gain rapid access to their online clinical records. Legally, patients in many countries already have the right to obtain copies of their health records; however, the practice known as “open notes” is different. Via secure online health portals, patients are now able to access their test results, lists of medications, and the very words that clinicians write about them. Open notes are growing with most patients in the Nordic countries already offered access to their full electronic record. From April 2021, a new federal ruling in the United States mandates—with few exemptions—that providers offer patients access to their online notes.
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