Key Considerations for Writing Good Patient Notes

Key Considerations for Writing Good Patient Notes 21st Century Cures Act mandate, came into effect in April, requires open patient access to clinical notes as part of its information blocking prohibition.

Sharing clinical notes can benefit both patients and physicians. Open Notes allow patients to view their clinical records on patient portals. These shared visit notes were created decades ago with the aim to improve patient experience. Today, this movement spread worldwide and millions of patients are viewing their clinical notes via the patient portal. The 21st Century Cures Act mandate covers eight types of clinical notes that medical transcription companies help healthcare providers create: 

Consultation

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Discharge summary

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Procedure notes

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Progress notes

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History and physical

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Imaging narratives

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Laboratory report narrative

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Pathology report narrative

According to the Open Notes organization, more than 50 million patients could access their clinical notes by the end of 2020. Studies of open notes have found that the strategy is indeed beneficial for patient. With the Cures act mandate, physicians will need to balance clinical documentation with a good patient experience.

Points to consider while preparing patient friendly clinical notes: 

Accuracy: According to Open Notes, when patients review their notes, accuracy improves as they become an extra set of eyes and sometimes find issues that require correcting.

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Patient- friendly: Physicians will have to work on making notes understandable for the patient and avoid any verbiage or phrases that can seem offensive or judgmental to patients. According to a study on clinical notes published in the Journal of General Internal Medicine, words like “incorrect,” “obese,” “wrong,” “anxious,” “depressed,” “inaccurate,” or “elderly” came up quite often as unfavorable to patients.

When writing open notes, clinicians should focus on:  Being positive and supportive.  Including only things discussed with the patient during that visit.  Not including wording that could be interpreted by the patient as labeling or judgmental.  Minimizing the use of medical jargon, acronyms, and abbreviations to avoid anything that may be perceived as offensive. 

Capture pertinent information for coding and clinical documentation improvement (CDI): The medical record is the source document for coding and reporting diagnoses and procedures. The goal of CDI is to improve the clinical note, which contains information

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captured during the visit such as present illness, data measured and recorded, examination observations, an assessment, a definitive diagnosis, and a care management plan. While providing open notes that are useful to the patient, clinicians must ensure precise documentation that supports the service/supply billed. This will promote accurate coding and billing, which can lead to correct and timely reimbursements for the healthcare provider. 

Consider practice-specific needs/concerns: The AMA says that when sharing patient notes, practices need to be ready to handle specific concerns such as:  whether notes created prior to open notes implementation will be shared  educating patients on registering in the patient portal and where to find their notes  how to answer patients’ questions on notes and correct any errors they find  how to handle sensitive topics like adolescent health, mental health, etc,

To successfully implement open notes, physicians should discuss the importance of transparency with their team and educate them on the benefits of open notes while addressing legal requirements. Family practice medical transcription service providers can ensure accurate documentation of consultations, procedures and progress notes, discharge summaries, history and physical, and imaging, laboratory, and pathology report narratives. They have experienced medical transcriptionists and quality assurance professionals on board who can ensure error -free documentation in the electronic health records (EHR), which will reduce the risk of errors in open notes.

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