How to ensure OpenNotes is a positive experience for patients

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With more than 6 million Americans now with access to their doctor’s notes through a patient portal, one doctor offers several suggestions for using them in a positive way.

Some doctors are apprehensive about patients reading their notes and have become “less candid” in their written assessments, according to a previous article in the Journal of the American Medical Association. However, the OpenNotes initiative aims to make doctor notes available to 50 million patients nationwide over the next three years.

To that end, brevity and clear language are keys to making open notes work for everyone involved, this writes Jared Klein, M.D. of Harborview Medical Center in Seattle in a commentary published in the American Journal of Medicine. He urges doctors to discuss what they write with patients, then write what was discussed.

Supportive language can help motivate patients, Klein says. For instance, he notes, a clinician could write, “The patient has lost five pounds and is motivated to continue this positive trend toward our goal of 20 pounds,” rather than “The patient still needs to lose another 15 pounds.” Frank but caring written words might help overcome denial or de-stigmatize a condition.

While HIPAA allows doctors to shield certain notes from patients in the rare case the doctor feels it would harm the patient, that should be discussed with the patient beforehand, Klein says.

Patients have the option to have certain legally, financially or socially sensitive information omitted from their written records.

Doctors should encourage patients to be actively involved in documenting their clinical visits, he says. Additionally, Klein notes, doctors should use feedback to better educate patients and strengthen rapport.