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A Patient-Centered Approach to Writing Ambulatory Visit Notes in the Cures Act Era
The 21st Century Cures Act Final Rule mandated that all U.S. patients have electronic access to clinical notes in 2021, encoding the cultural shift toward health information transparency into law. This landmark policy change, along with similar efforts around the world,     provides an opportunity to reflect on the purpose of clinical notes and their impact on both clinicians and patients. Clinical informaticists and medical educators are key leaders in supporting current and future clinicians in this new health care environment.
Historians suggest that the medical record has existed for thousands of years, initially for educational purposes and then later as a direct part of patient care. In 1968, Weed published recommendations for a “problem-based” computerized medical record after observing challenges with written notes including disorganization, inefficiencies, and missing information. Migration from paper charts to electronic health records (EHRs) accelerated in the 21st century with federal legislation encouraging adoption. Electronic notes became more structured, but new challenges related to note quality and clinician burnout emerged.   Today's clinical notes are beholden to a broad audience, having evolved from clinician communication tools into documents that must also satisfy billing, legal, and compliance requirements. Inviting patients as yet another audience member through “open notes” signifies a new era in health care and health technology.
Since the original open notes study in 2010, patient access to electronic notes has increased worldwide and is now nearly universal in the United States.    Patients want to read their notes, are learning from them,  and report several benefits, including increased participation in care. Research shows that patient engagement is associated with better outcomes and lower costs,     but sharing visit notes also raises clinician anxiety and concerns about patient worry.       Clinicians need low-burden, high-impact strategies for writing patient-centered notes that uphold communication between clinicians.
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. Consolidating research findings from the last decade, we address both practical and thorny issues related to transparent notes and summarize 10 strategies for writing notes that patients read ([Table 1]), organized under four overarching patient-centered principles.
Engage patients and strengthen the patient–clinician relationship
In multiple studies across different organizations, patients consistently reported greater engagement from reading notes.    Patients better remembered and understood the care plan, tests, and referrals. Shared notes also promoted self-management in patients with chronic illnesses. In a study of patients with chronic obstructive pulmonary disease, half of whom met criteria for limited English proficiency, 85% reported that reading notes motivated behavior changes such as increased exercise, smoking cessation, and improved adherence to medications. Knowing this, clinicians should clearly outline the care plan, briefly describe the rationale for clinical decisions, and encourage patients to read notes between visits.
Patients have also highlighted enhanced relationships with clinicians as what they value about reading notes. An invitation to read notes sends a message of partnership and inclusivity. To strengthen these relationships, clinicians can use partnering language such as “We decided,” reinforcing the patient's role in their care. Encouraging statements can acknowledge patient successes, for example, celebrating weight loss while recognizing that there are additional pounds to shed. Statements that use the word “yet” (The patient has not been able to quit smoking yet) can also foster a mindset of future growth.
2 Partner with patients to improve note accuracy
Reading notes provides a tangible opportunity for patients to identify errors and misalignments that can lead to adverse events.   Misalignments are mismatches between patient and clinician perspectives on symptoms, events, or their significance. Clinicians can avoid misalignments by eliciting the patient's priorities and negotiating a shared agenda for the visit, including the rationale for prioritizing any items that were not on the patient's list. Some clinicians type or dictate notes with the patient in the room, and can pause to confirm key elements with the patient. Other clinicians routinely embed a statement at the end of each note asking for feedback if they did not get the story right.
Note templates can also lead to misalignments. This may be due to imported data crowding out relevant information, “copy forward” of outdated histories, or use of automated text that does not reflect what happened at the visit. For example, clinicians may inadvertently use a full physical exam template when only specific parts were done, or import a full review of systems into the note. The patient may then perceive questions that were not asked, and responses that may be erroneous.   Clinicians can combat misalignments and save time by documenting relevant information only. With the new ambulatory care Centers for Medicare and Medicaid Services billing requirements, clinicians should be empowered to focus on essential text. Examples of shorter, higher quality notes that better capture the patient story can be useful educational tools. New technologies that record the visit and automatically generate a focused visit note may help reduce these problems in the future.
Another potential cause of misalignments is that notes are written after the visit, sometimes days after the actual encounter. This practice allows clinicians to reflect on the encounter or get results before formulating a care plan in the note, but can result in a new assessment that was not discussed at the visit. Statements such as “after consideration…,” or “after discussion with my colleagues…,” can show that further critical thinking took place after the visit. This approach has the added benefit of making visible to patients the additional time spent on their care, a factor that may enhance positive relational effects. 
Whether due to faulty use of templates, new information, or undisclosed clinician concerns or diagnoses, surprises in the note can be off-putting or anxiety-provoking to patients. A good rule of thumb is to “write what you say and say what you write,” reinforcing the visit. Transparent notes require good communication and transparent care.
Clinicians should also be prepared to address potential documentation errors. In prior studies, 24% of clinicians anticipated nontrivial errors in their notes and 21% of patients reported finding an error.  For a minority of patients, errors can reinforce preexisting negative attitudes about clinicians,  particularly if their efforts to fix the error are ignored.   However, many patients who perceive errors focus on working with clinicians to improve accuracy. Teaching clinicians to discuss errors with an emphasis on compassionate communication is important. Patients may identify errors in notes before clinicians are aware of them, requiring clinicians to listen first and respond meaningfully thereafter. Clinicians can distinguish between factual errors such as type II diabetes versus type I diabetes, and medical opinions, like whether a fall was related to alcohol use. They can practice reassurance about correcting factual errors while reserving the right to their medical opinions. They can also “agree to disagree” with patients and document both opinions in the note. These challenging situations should first be managed with clear communication during the visit. The note is just one part of the patient–clinician relationship and should serve to support, not replace, face-to-face discussion.
Clinicians should also be aware of how to correct errors. The medical records department should be contacted for major errors, such as notes entered on the wrong patient. While smaller errors are typically handled with an addendum, patients have shared that an addendum can feel dismissive and does not correct the underlying error, nor the risk of propagating the error. Clinicians should tell patients about limitations to corrections in the EHR, and clinical informaticists can help by developing more effective solutions.
3 Respect patients by avoiding judgmental and stigmatizing language
Many clinicians worry about how to document sensitive topics. However, patients have long had a right to read their medical record through the Health Insurance Portability and Accountability Act (HIPAA), and studies have shown overall benefit when sharing notes with broad patient populations including pediatric and mental health patients.   Toolkits are available for support,   with recommendations focusing on the use of nonjudgmental descriptions. Clinicians can describe “a patient with schizophrenia” rather than using the term “schizophrenic,” report their patient “drinks five beers a day” rather than writing “alcoholic,” or document a patient's body mass index rather than writing “morbidly obese.”   Clinicians should be mindful of autoimported text that contains sensitive information, particularly in the care of adolescents or other individuals with health care proxies who may access the record. In rare instances where reading notes may harm patients, clinicians may choose to block note access. Clinicians should be familiar with information blocking rules and discuss the reason with the patient. At some organizations, clinical informaticists have embedded a reminder requiring clinicians to select one of the information blocking exceptions before restricting patient access to the note.
Stigmatizing language in the medical record can be particularly offensive to patients and may bias other clinicians or even change prescribing behaviors.   Clinicians can avoid language that casts doubt on the patient (replacing “He claims” or “He denies” with “He says”), or that may be perceived as stereotypical (replacing “She is hysterical” with “She is worried”). Extraneous details, quotes of poor grammar, or emphasis on a person's socioeconomic status should be avoided if irrelevant to care.  Many organizations are already engaged in efforts to recognize and reduce implicit bias in care. These efforts should be extended to note-writing so that stigmatizing language is replaced with neutral words.
4 Encourage patients to access and read notes
The benefits from reading notes rely on patient access to notes. Despite the Cures Act, many patients do not know about note access, do not use the patient portal, or do not read notes.  In particular, digital divides may limit portal registration among underserved groups, and implicit bias regarding who benefits can affect clinicians' recommendations to enroll some patients.  Early studies suggest that sharing notes provides similar or greater benefits to less educated patients, those who speak a language other than English at home, patients who self-identify as persons of minority races or ethnicities, older individuals with chronic illnesses, and the care partners who support them—although larger studies and more robust equity efforts are needed.    Broader support for patient access to health information is consistent with Equity, Diversity, and Inclusion priorities. Several studies underscore the critical role of clinician encouragement for portal registration and note-reading,   and clinicians should encourage all patients to read their notes, in concert with organizational efforts to promote health information equity.
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Article published online:
08 March 2023
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- 1 United States Department of Health and Human Services. 21st Century Cures Act: H.R. 34, 114th Cong; 2015
- 2 Digital NHS. Access to patient records through the NHS App. 2022. Accessed November 25, 2022, at: https://digital.nhs.uk/services/nhs-app/nhs-app-guidance-for-gp-practices/guidance-on-nhs-app-features/accelerating-patient-access-to-their-record
- 3 Moll J, Rexhepi H, Cajander Å. et al. Patients' experiences of accessing their electronic health records: National Patient Survey in Sweden. J Med Internet Res 2018; 20 (11) e278
- 4 Rahbek Nørgaard J. E-record - access to all Danish public health records. Stud Health Technol Inform 2013; 192: 1121
- 5 Tiik M, Ross P. Patient opportunities in the Estonian Electronic Health Record System. Stud Health Technol Inform 2010; 156: 171-177
- 6 Salmi L, Brudnicki S, Isono M. et al. Six countries, six individuals: resourceful patients navigating medical records in Australia, Canada, Chile, Japan, Sweden and the USA. BMJ Open 2020; 10 (09) e037016
- 7 Gillum RF. From papyrus to the electronic tablet: a brief history of the clinical medical record with lessons for the digital age. Am J Med 2013; 126 (10) 853-857
- 8 Weed LL. Medical records that guide and teach. N Engl J Med 1968; 278 (11) 593-600
- 9 Health IT. gov. Health IT Dashboard. National trends in hospital and physician adoption of electronic health records. Accessed November 25, 2022, at: https://www.healthit.gov/data/quickstats/national-trends-hospital-and-physician-adoption-electronic-health-records
- 10 Ratwani RM, Reider J, Singh H. A decade of health information technology usability challenges and the path forward. JAMA 2019; 321 (08) 743-744
- 11 Tai-Seale M, Olson CW, Li J. et al. Electronic health record logs indicate that physicians split time evenly between seeing patients and desktop medicine. Health Aff (Millwood) 2017; 36 (04) 655-662
- 12 Gardner RL, Cooper E, Haskell J. et al. Physician stress and burnout: the impact of health information technology. J Am Med Inform Assoc 2019; 26 (02) 106-114
- 13 Downing NL, Bates DW, Longhurst CA. Physician burnout in the electronic health record era: are we ignoring the real cause?. Ann Intern Med 2018; 169 (01) 50-51
- 14 Delbanco T, Walker J, Bell SK. et al. Inviting patients to read their doctors' notes: a quasi-experimental study and a look ahead. Ann Intern Med 2012; 157 (07) 461-470
- 15 Open Notes. Accessed August 31, 2022, at: http://www.opennotes.org
- 16 Müller J, Ullrich C, Poss-Doering R. Beyond known barriers-assessing physician perspectives and attitudes toward introducing open health records in Germany: qualitative study. J Particip Med 2020; 12 (04) e19093
- 17 Belyeu BM, Klein JW, Reisch LM. et al. Patients' perceptions of their doctors' notes and after-visit summaries: a mixed methods study of patients at safety-net clinics. Health Expect 2018; 21 (02) 485-493
- 18 Mishra VK, Hoyt RE, Wolver SE, Yoshihashi A, Banas C. Qualitative and quantitative analysis of patients' perceptions of the patient portal experience with OpenNotes. Appl Clin Inform 2019; 10 (01) 10-18
- 19 Turer RW, Martin KR, Courtney DM. et al. Real-time patient portal use among emergency department patients since implementation of the 21st Century Cures Act: an open results study. Appl Clin Inform 2022; DOI: 10.1055/a-1951-3268.
- 20 Greene J, Hibbard JH, Sacks R, Overton V, Parrotta CD. When patient activation levels change, health outcomes and costs change, too. Health Aff (Millwood) 2015; 34 (03) 431-437
- 21 Woods SS, Schwartz E, Tuepker A. et al. Patient experiences with full electronic access to health records and clinical notes through the My HealtheVet Personal Health Record Pilot: qualitative study. J Med Internet Res 2013; 15 (03) e65
- 22 Nazi KM, Turvey CL, Klein DM, Hogan TP, Woods SSVA. VA OpenNotes: exploring the experiences of early patient adopters with access to clinical notes. J Am Med Inform Assoc 2015; 22 (02) 380-389
- 23 Dentzer S. Rx for the ‘blockbuster drug’ of patient engagement. Health Aff (Millwood) 2013; 32 (02) 202-202
- 24 Crotty BH, Anselmo M, Clarke DN. et al. Opening residents' notes to patients: a qualitative study of resident and faculty physician attitudes on Open Notes implementation in graduate medical education. Acad Med 2016; 91 (03) 418-426
- 25 Tang PC, Smith MD. Democratization of health care. JAMA 2016; 316 (16) 1663-1664
- 26 Walker J, Leveille SG, Ngo L. et al. Inviting patients to read their doctors' notes: patients and doctors look ahead: patient and physician surveys. Ann Intern Med 2011; 155 (12) 811-819
- 27 Klein JW, Jackson SL, Bell SK. et al. Your patient is now reading your note: opportunities, problems, and prospects. Am J Med 2016; 129 (10) 1018-1021
- 28 Walker J, Leveille S, Bell S. et al. OpenNotes after 7 years: patient experiences with ongoing access to their clinicians' outpatient visit notes. J Med Internet Res 2019; 21 (05) e13876
- 29 Bell SK, Roche SD, Mueller A. et al. Speaking up about care concerns in the ICU: patient and family experiences, attitudes and perceived barriers. BMJ Qual Saf 2018; 27 (11) 928-936
- 30 Fisher KA, Kennedy K, Bloomstone S, Fukunaga MI, Bell SK, Mazor KM. Can sharing clinic notes improve communication and promote self-management? A qualitative study of patients with COPD. Patient Educ Couns 2022; 105 (03) 726-733
- 31 Gerard M, Chimowitz H, Fossa A, Bourgeois F, Fernandez L, Bell SK. The importance of visit notes on patient portals for engaging less educated or nonwhite patients: survey study. J Med Internet Res 2018; 20 (05) e191
- 32 Kahn MW, Bell SK, Walker J, Delbanco T. A piece of my mind. Let's show patients their mental health records. JAMA 2014; 311 (13) 1291-1292
- 33 Stuart M. Lieberman JA III, Semour J. The Fifteen Minute Hour: Therapeutic Talk in Primary Care. 4th ed. Abingdon, Oxfordshire: Radcliffe Publishing; 2008
- 34 Bell SK, Delbanco T, Elmore JG. et al. Frequency and types of patient-reported errors in electronic health record ambulatory care notes. JAMA Netw Open 2020; 3 (06) e205867
- 35 Bell SK, Gerard M, Fossa A. et al. A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships. BMJ Qual Saf 2017; 26 (04) 312-322
- 36 Bell SK, Mejilla R, Anselmo M. et al. When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient-doctor relationship. BMJ Qual Saf 2017; 26 (04) 262-270
- 37 Sinclar CT. Sharing Palliative Care Notes. 2020. Accessed September 1, 2022, at: https://www.opennotes.org/news/grand-rounds-webinar-sharing-palliative-care-notes/
- 38 Bell SK, Bourgeois F, DesRoches CM. et al. Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care. BMJ Qual Saf 2022; 31 (07) 526-540
- 39 Fernández L, Fossa A, Dong Z. et al. Words matter: what do patients find judgmental or offensive in outpatient notes?. J Gen Intern Med 2021; 36 (09) 2571-2578
- 40 Association AM. CPT Evaluation and Management (E/M). Accessed January 26, 2022, at: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
- 41 Gantzer HE, Block BL, Hobgood LC, Tufte J. Restoring the story and creating a valuable clinical note. Ann Intern Med 2020; 173 (05) 380-382
- 42 Nuance. Explore Nuance DAX for clinicians. Accessed November 25, 2022, at: https://www.nuance.com/healthcare/ambient-clinical-intelligence/explore-dax-for-clinicians.html
- 43 Chin MH. Advancing health equity in patient safety: a reckoning, challenge and opportunity. BMJ Qual Saf 2020:bmjqs-2020-012599
- 44 Gerard M, Fossa A, Folcarelli PH, Walker J, Bell SK. What patients value about reading visit notes: a qualitative inquiry of patient experiences with their health information. J Med Internet Res 2017; 19 (07) e237
- 45 Bourgeois FC, Fossa A, Gerard M. et al. A patient and family reporting system for perceived ambulatory note mistakes: experience at 3 U.S. healthcare centers. J Am Med Inform Assoc 2019; 26 (12) 1566-1573
- 46 Agency for Healthcare Research and Quality. Communication and Optimal Resolution (CANDOR) Toolkit. 2016. Accessed January 26, 2022, at: https://www.ahrq.gov/patient-safety/capacity/candor/modules.html
- 47 Bell SK, Folcarelli PH, Anselmo MK, Crotty BH, Flier LA, Walker J. Connecting patients and clinicians: the anticipated effects of open notes on patient safety and quality of care. Jt Comm J Qual Patient Saf 2015; 41 (08) 378-384
- 48 Lam BD, Bourgeois F, Dong ZJ, Bell SK. Speaking up about patient-perceived serious visit note errors: Patient AND family experiences and recommendations. J Am Med Inform Assoc 2021; 28 (04) 685-694
- 49 United States Department of Health and Human Services. The Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, 110 Stat. 1936; 1996
- 50 Bialostozky M, Huang JS, Kuelbs CL. Are you in or are you out? Provider note sharing in pediatrics. Appl Clin Inform 2020; 11 (01) 166-171
- 51 Sarabu C, Lee T, Hogan A, Pageler N. The value of OpenNotes for pediatric patients, their families and impact on the patient-physician relationship. Appl Clin Inform 2021; 12 (01) 76-81
- 52 Denneson LM, Chen JI, Pisciotta M, Tuepker A, Dobscha SK. Patients' positive and negative responses to reading mental health clinical notes online. Psychiatr Serv 2018; 69 (05) 593-596
- 53 Open Notes. Open Notes Mental Health Toolkit. Accessed September 1, 2022, at: http://www.opennotes.org/wp-content/uploads/2020/06/OpenNotes_Mental-Health_Toolkit.pdf
- 54 Volger S, Vetter ML, Dougherty M. et al. Patients' preferred terms for describing their excess weight: discussing obesity in clinical practice. Obesity (Silver Spring) 2012; 20 (01) 147-150
- 55 Murugan A, Gooding H, Greenbaum J. et al. Lessons learned from OpenNotes learning mode and subsequent implementation across a pediatric health system. Appl Clin Inform 2022; 13 (01) 113-122
- 56 Goddu AP, O'Conor KJ, Lanzkron S. et al. Correction to: Do Words Matter? Stigmatizing language and the transmission of bias in the medical record. J Gen Intern Med 2019; 34 (01) 164
- 57 Kelly JF, Westerhoff CM. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. Int J Drug Policy 2010; 21 (03) 202-207
- 58 Beach MC, Saha S. Quoting patients in clinical notes: first, do no harm. Ann Intern Med 2021; 174 (10) 1454-1455
- 59 Beach MC, Saha S, Park J. et al. Testimonial injustice: linguistic bias in the medical records of black patients and women. J Gen Intern Med 2021; 36 (06) 1708-1714
- 60 Raney J, Pal R, Lee T. et al. Words matter: an antibias workshop for health care professionals to reduce stigmatizing language. MedEdPORTAL 2021; 17: 11115
- 61 Everson J, Patel V, Adler-Milstein J. Information blocking remains prevalent at the start of 21st Century Cures Act: results from a survey of health information exchange organizations. J Am Med Inform Assoc 2021; 28 (04) 727-732
- 62 Open Notes. Implementing OpenNotes: Improving patient access to notes on patient portals (An OpenNotes white paper). Accessed Accessed: January 18, 2023 at: http://www.opennotes.org/wp-content/uploads/2019/01/Implementing_OpenNotes_Improving_Patient_Access_to_Notes_on_Patient_Portals.pdf
- 63 Bush RA, Vemulakonda VM, Richardson AC, Deakyne Davies SJ, Chiang GJ. Providing access: differences in pediatric portal activation begin at patient check-in. Appl Clin Inform 2019; 10 (04) 670-678
- 64 Chimowitz H, Gerard M, Fossa A, Bourgeois F, Bell SK. Empowering informal caregivers with health information: OpenNotes as a safety strategy. Jt Comm J Qual Patient Saf 2018; 44 (03) 130-136
- 65 DesRoches CM, Salmi L, Dong Z, Blease C. How do older patients with chronic conditions view reading open visit notes?. J Am Geriatr Soc 2021; 69 (12) 3497-3506
- 66 Irizarry T, DeVito Dabbs A, Curran CR. Patient portals and patient engagement: a state of the science review. J Med Internet Res 2015; 17 (06) e148 DOI: 10.2196/jmir.4255.
- 67 Vydra TP, Cuaresma E, Kretovics M, Bose-Brill S. Diffusion and use of tethered personal health records in primary care. Perspect Health Inf Manag 2015; 12 (Spring): 1c
- 68 Shenkin BN, Warner DC. Sounding board. Giving the patient his medical record: a proposal to improve the system. N Engl J Med 1973; 289 (13) 688-692
- 69 Slack WV, Hicks GP, Reed CE, Van Cura LJ. A computer-based medical-history system. N Engl J Med 1966; 274 (04) 194-198