FAQs for Clinicians
Will open notes increase patient safety?
Data on transparent communication in health care (such as disclosure of medical error) suggest that open and honest communication may improve patient safety and decrease lawsuits (Kachalia Ann Intern Med 2010). In the OpenNotes study, some providers listed improved patient safety as the “best thing” about sharing their notes with patients.
Will open notes affect clinicians’ work flow?
Patients are generally respectful of clinicians’ time, and most doctors who participated in the OpenNotes study reported little, if any, impact on their daily practice. Many reported that they actually forgot that they were participating in the study after enrolling. After a year, only a small minority reported that participating took more time, while others thought it saved time.
Will patients contact their doctors more between visits?
While a small number of patients will contact their doctor, nurse or clinician more after reading their notes, the OpenNotes study participants found this uncommon. Moreover, many health professionals found that these communications were important for patient care and satisfaction. Some patients may contact providers less by virtue of having access to their notes.
Will patients be more confused or anxious by reading their notes?
Of all patients in the OpenNotes study, only a small minority found the notes more confusing than helpful, felt offended, or worried more as a result of reading their doctors’ visit notes. Patients were not generally bothered by medical terms, but rather reported looking up or “Googling” medical terms online to learn more about their doctors’ notes and their conditions.
What if I want to write something that I don’t want my patients to read?
A first step is to remember that, with a few exceptions, all notes are already “open” because under the Health Insurance Portability and Accountability Act (HIPAA), patients are entitled to obtain a copy of their complete medical record. Therefore, your documentation should be written with this in mind, regardless of whether you are actively sharing visit notes with your patients.
And in the OpenNotes study, providers found that when some patients read notes about sensitive issues, such as mental health, obesity, or substance abuse, they ended up more motivated to make difficult behavioral changes.
What if patients disagree with the note and want it changed?
In the Open Notes study, patients only rarely requested a change in the note. In some cases it was because of inaccuracy of information, and the change may well have improved their safety.
Your practice likely has a policy for changing notes, and in many cases, an addendum may suffice.