Improving health outcomes, through better communication and engagement with patients, is a cornerstone of practice in the military health care system. The MHS GENESIS electronic health record contributes to standardizing the delivery of care for this best practice, in particular via its patient portal. The portal includes the first MHS implementation of the concept of open notes, which allows patients to access the notes providers write to document each clinical encounter.
Open Notes offer many evidence-based benefits through mutual communication, understanding and collaboration. Even so, some vendors are a bit cautious about the approach. These clinicians are concerned that patients may misinterpret or disagree with the content of the note, which could lead to interpersonal friction or undesirable clinical outcomes.
There is no doubt that encouraging patients to explore their providers’ perspective on clinical interactions fundamentally changes their relationship with providers. However, adapting to open notes is easier than you might think and helps providers meet patients where they are and build stronger, more reliable relationships. Open Notes enable two-way communication and feedback that encourages providers and patients to feel that they are not just on the same page, but in the same boat on a shared journey.
Flip the script
Traditionally, vendors have written their session notes to communicate only with other vendors. Patients can get a copy of their chart, but they rarely, if ever, read it often because their providers do not encourage them and they have to go through heavy jargon if they do. Open Notes reverse this script by giving patients on-demand access to their providers’ observations and instructions and encourage clear dialogue about this content.
As providers, we can encourage patients to take advantage of the open notes at each session by asking them, âDid you read the note from the last appointment? If so, is there anything that was not clear or that you have questions about? ”
The patient can read the note and say, “Oh, I have to stop this medicine and start this one.” They can clarify, âHey, the note says this, but it’s not correctâ or ask, âI need to understand, what did you mean by that? “
A matter of trust
Open notes provide a crucial opportunity to ensure that the medical record is complete, accurate and mutually understood. It is not uncommon for a provider to think they have communicated a treatment plan and the patient to hear something else. Every provider has been a patient at some point, and we’ve all had times when we a) forget important questions we wanted to ask and b) may not remember what our providers have told us.
Open notes allow patients and providers to deepen their relationship and their bond of trust. It is especially important to maintain this confidence now that patients often come for visits after researching their symptoms and possible conditions and treatments. If what you are saying does not match what they have seen online, they may have less confidence in you or your clinical abilities.
Trust is at the heart of all supplier-patient relationships. Ultimately, the success of the treatment plan isn’t what you say or recommend as a provider – it’s what the patient decides to do with it based on their confidence in you.
Opportunities to learn
Open notes can also increase patient education. Notes can link to websites and other documents that patients can refer to as part of the treatment plan – or even provide homework for patients to do between appointments.
The Defense Health Agency has many resources to help SHM providers learn how to write open notes as well, including this cheat sheet and webinar. Here are three tips you can easily incorporate into open note writing:
1. Step into the role of the patient. What would you like to know about the provider’s observations and recommendations, especially the diagnostic assessment and treatment plan that you would like to read later? What would you like to share with your family and your support network?
2. Use plain language without medical or military jargon. Patients are only going to improve if they understand the treatment plan – and how are they going to comply with it if they can’t understand what it says?
3. Include only the information that needs to be present. Be focused and concise, including information that supports the diagnosis and treatment plan, and omitting unnecessary personal details.
An example of an open note
Let’s say you have met a patient who has a relationship problem. In your open conversation note, do not share details of an argument the patient had that said what to whom.
Instead, you can write something like, âThe patient discussed some challenges in their relationship and we explored various ways to improve communication in that relationship. The patient left with the following tools, which I asked him to train in the future. If you are a follow-up provider, you can see that the patient has had relationship difficulties and has a treatment plan in place. If you need details, you can ask the patient.
Think of an open note as a repetition of high-level teachings from your meeting, which the patient can review each time they read it. By treating every dating note like an open note, you can be sure that you are following a best practice that is spreading every day. Open Notes give you, as a provider, the opportunity to demonstrate your commitment to improving outcomes by increasing patient engagement, one note at a time.
Dr. Simon Pincus is the Clinical Director of the Defense Health Agency’s Medical Affairs Behavioral Health Management Team.
Dr Robert Ciulla is the team leader of the Information Center of the Directorate General of Connected Health of the Defense Health Agency.
|Date posted:||14.14.2021 16:13|
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