Be transparent with patients
The shift to patient-centered care is designed to help patients be part of the decision-making process. But that requires openness and communication by the physician about information in the medical record.
One approach physicians can take to boost transparency and encourage more patient engagement is to share notes with their patients, says Nitin Damle, MD, an internist with South County Internal Medicine in Wakefield, Rhode Island, and president of the American College of Physicians. Doctors may hesitate to do so out of fear that misunderstood comments could lead to lawsuits, but the idea is not unreasonable, he says.
While note-sharing can be tricky if done without appropriate context, it can be helpful when done under the right circumstances, Damle says. Discussing entries with patients promotes more engagement, and helps them become more active participants. “That can lead to better outcomes and enhance the doctor-patient relationship,” he adds.
Whether shared in person or through an online portal, physicians should take time to explain what the notes mean, such as why a test or medication was ordered, he says. Additionally, patients should never be permitted to directly modify anything in their chart. If they do need to add information, it should go in as an addendum.
Note sharing helps physicians be more careful about using objective language when describing patient encounters. Damle says common sense should prevail when discussing a patient’s record. Entries should be factual and not derogatory or personal in any way. Keep to the medical specifics of a visit, call or referral, he advises.
Robin Diamond, JD, MSN, chief patient safety officer for physician insurer The Doctors Company, points out that notes need to be objective and unambiguous. “Think about how you’d feel if you saw them projected on a six-foot screen in a courtroom or if they were in the family’s or patient’s possession,” she says.
To increase clarity, she suggests including direct quotes from patients when documenting, especially if the patient seems upset or agitated.
Diamond recommends also that physicians and patients review the notes together. Not only does this practice ensure that entries are appropriate and objective, she adds, it helps patients better understand their situation and any required action on their part. That reduces the potential for claims arising from miscommunication or misunderstandings.