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,[1] encoding the cultural shift toward health information transparency into law. This landmark policy change, along with similar efforts around the world,[2] [3] [4] [5] [6] 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.[7] In 1968, Weed published recommendations for a “problem-based” computerized medical record after observing challenges with written notes including disorganization, inefficiencies, and missing information.[8] Migration from paper charts to electronic health records (EHRs) accelerated in the 21st century with federal legislation encouraging adoption.[9] Electronic notes became more structured, but new challenges related to note quality and clinician burnout emerged.[10] [11] [12] Today's clinical notes are beholden to a broad audience,[13] 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,[14] patient access to electronic notes has increased worldwide and is now nearly universal in the United States.[2] [6] [15] [16] Patients want to read their notes,[17] are learning from them,[18] [19] and report several benefits, including increased participation in care.[14] Research shows that patient engagement is associated with better outcomes and lower costs,[14] [20] [21] [22] [23] but sharing visit notes also raises clinician anxiety and concerns about patient worry.[14] [16] [21] [22] [24] [25] [26] 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.[27] 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.

Table 1 Patient-centered tips for clinicians to write notes that patients read

Patient-centered principle	Strategy
Engage patients and strengthen the patient-clinician relationship	1. Include a brief rationale for tests, referrals, and medications to promote engagement
	2. Recognize and empower patients as team members. Consider partnering language such as “We decided”
	3. Celebrate patient successes. Encourage future behavioral or self-management changes by using the word “yet”
Partner with patients to improve note accuracy	4. Create a shared visit agenda and document patient values and preferences to help patients see themselves in the note
	5. Encourage patient feedback on notes and respond compassionately to errors. Differentiate between inaccurate medical facts (that should be corrected) and clinical opinions. Agree to disagree when needed
	6. Less is more. Avoid copy/paste behaviors and the excessive use of templates, imported data, and jargon
	7. Avoid surprises in the note: “Discuss what you write and write what you discuss”
Respect patients by avoiding judgmental and stigmatizing language	8. Address sensitive topics respectfully. Describe rather than label
	9. Recognize and replace judgmental or stigmatizing language with neutral language to avoid transmission of bias through the medical record
Encourage patients to access and read notes	10. Encourage all patients to read their notes between visits, in concert with organizational health information equity efforts to improve access Note: Organizations can engage patient and family advisory committees to co-develop educational materials on what to expect from notes and how to help patients get the most out of notes. They can also support efforts to better understand and address engagement disparities

1. Engage patients and strengthen the patient–clinician relationship

In multiple studies across different organizations, patients consistently reported greater engagement from reading notes.[14] [15] [22] [28] Patients better remembered and understood the care plan, tests, and referrals.[29] 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.[30] 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.[31] 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,[32] for example, celebrating weight loss while recognizing that there are additional pounds to shed.[27] Statements that use the word “yet” (The patient has not been able to quit smoking yet) can also foster a mindset of future growth.[33]

• 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.[34] [35] [36] 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.[37]

Note templates can also lead to misalignments. This may be due to imported data crowding out relevant information, “copy forward” of outdated histories,[34] or use of automated text that does not reflect what happened at the visit.[38] 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.[27] [34] [39] 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,[40] 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.[41] New technologies that record the visit and automatically generate a focused visit note may help reduce these problems in the future.[42]

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.[34] 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.[36] [37]

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.[27] 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.[34] [35] For a minority of patients, errors can reinforce preexisting negative attitudes about clinicians,[39] [43] particularly if their efforts to fix the error are ignored.[35] [44] [45] 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.[46] Patients may identify errors in notes before clinicians are aware of them, requiring clinicians to listen first and respond meaningfully thereafter.[47] 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.[27] 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.[32] 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.[48] 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.[24] However, patients have long had a right to read their medical record through the Health Insurance Portability and Accountability Act (HIPAA),[49] and studies have shown overall benefit when sharing notes with broad patient populations including pediatric and mental health patients.[50] [51] [52] Toolkits are available for support,[15] [27] [53] 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.”[27] [37] [54] 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.[39] [56] [57] 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.[58] [59] 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.[60]

• 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.[61] [62] In particular, digital divides may limit portal registration among underserved groups,[63] and implicit bias regarding who benefits can affect clinicians' recommendations to enroll some patients.[31] [63] 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.[30] [31] [64] [65] Broader support for patient access to health information is consistent with Equity, Diversity, and Inclusion priorities.[43] Several studies underscore the critical role of clinician encouragement for portal registration and note-reading,[65] [66] [67] and clinicians should encourage all patients to read their notes, in concert with organizational efforts to promote health information equity.

Summary

Today's clinicians practice in an environment that is different than the one in which they learned. Managing the uncertainty around new transparent documentation practices can feel overwhelming, especially in time-constrained settings. But federally mandated information sharing means clinical informaticist leaders and medical educators need to take steps to prepare clinicians. Our proposed patient-centered approach to writing notes is derived from research on how patients experience note-reading and focuses on leveraging benefits while minimizing risks ([Table 1]).

Clinician burnout from documentation remains a critical concern and note-writing should focus on shorter notes that highlight how small changes in language can positively impact both patients and clinicians.[33] [37] [40] No doubt the clinical note will continue to evolve as informaticists continue to advance health technology. Nearly 50 years ago, Shenkin and Warner argued that patient access to medical records would improve care,[68] and Warner Slack showed how a patient answering questions on a computer could revolutionize clinical notes.[69] As patients emerge as partners in their notes through policy change, we have an opportunity to think creatively about what notes look like and how patients and clinicians can most effectively interface with the EHR. Patient and family advisory council members and patient advocacy groups can also be important partners in innovation, helping both to guide clinicians and set expectations with patients.

Although a decade of research sets the foundation for a patient-centered approach to writing notes, studies with more diverse patients are needed. Further research on these tactics with a focus on assessing note quality and patient and clinician experiences can refine our proposed strategies.

 

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Clinical Relevance Statement

Research shows that sharing visit notes with patients creates opportunities for partnership but there are no existing patient-centered guidelines or curricula for clinicians to learn how to write notes that patients read. We review a decade of open notes research and summarize 10 strategies for how to write patient-centered notes.

 

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Multiple-Choice Questions

1. Research on open notes has shown that patients who read visit notes can:

   • Better remember diagnostic tests

   • Better remember referrals to other clinicians

   • Better understand the purpose of their medications

   • All of the above

   Correct Answer: The correct answer is option d. Prior studies on open notes have shown that patients report greater engagement from reading notes, identifying benefits such as better remembering and understanding their medications, tests, and referrals.

2. Clinicians can avoid perpetuating judgment and bias in their notes by:

   • Quoting patients directly in the note to highlight slang and poor grammar

   • Including details such as the patient's race or socioeconomic status when not relevant to care

   • Describing rather than labeling, for example, documenting how much alcohol a patient drinks rather than using the term “alcoholic”

   • Using language that casts doubt on the patient, such as “He claims”

   Correct Answer: The correct answer is option c. Research has shown that judgmental or stigmatizing language can bias clinicians and even affect prescribing behaviors. Quoting slang or poor grammar and highlighting a person's race or socioeconomic status should be avoided if it is irrelevant to their care. Language that casts doubt on the patient or perpetuates stereotypes should be replaced with neutral words. Clinicians should describe patients and their preferences rather than labeling them.

 

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Conflict of Interest

None declared.

Acknowledgments

The authors thank the Open Notes team for contributions to note-writing strategies, the patients and families who shared their insights about reading notes, and Cait DesRoches and Kelly Graham for their thoughtful review of the manuscript.

Protection of Human and Animal Subjects

None.

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Publication History

Article published online:
08 March 2023