Sept / Oct 2022 | michigan MEDICINE® 15 When composing notes, certain strategies raise the odds that notes will be well understood and well received. Beyond being clear and succinct, strategies for success include: 1. Invite patients to participate in the note-writing process: During the visit, ask patients to read their notes, and check for understanding and accuracy. Encourage patients to refer to notes. 2. Consider beginning your note with the Assessment and Plan section. Many EHR systems allow your locking style to change based on your needs, i.e., you document in a typical subjective, objective, assessment, and plan (SOAP) format, but once locked, the assessment and plan are front and center. Include only pertinent aspects of current visits, and avoid importing multiple pages of data available elsewhere in the EHR. 3. Consider composing at least a portion of the note as instructions addressed directly to the patient. More direct language may help reinforce instructions for patients. For example: “Start taking lisinopril and check your blood pressure twice a week,” vs. “Initiated lisinopril and instructed her to check her blood pressure twice a week.” 4. When possible, use boldface text or other visual emphasis to call out important items such as “check your blood sugar twice a day.” 5. Avoid jargon. Patients don’t expect layperson’s terminology, but they need to be able to follow the note. 6. Make technology work for you. Use electronic tools to convert abbreviations to full spelling. Create templated versions of explanations that you frequently provide. 7. If you must use some shortened terms, take care to avoid those that might be particularly offensive if misconstrued. For example, a physician might use the accepted abbreviation for “follow up regarding shortness of breath,” “which could easily be misunderstood by a patient. 8. Caution patients about the potential for misunderstandings, and/or include templated statements and offer a list of common medical abbreviations. Another solution is inserting links to reliable online resources for clarification regarding medical terms. 9. Directly and respectfully address concerns. For example, for patients with obesity, review body mass index to clarify that emotionally fraught terms like overweight, obese, and morbidly obese are clinical terms, and not subjective judgments imposed by the physician. 10. Use supportive, nonjudgmental language. For example: “Patient lost five pounds and is motivated to continue positive trend toward goal of 20 pounds” vs. “Patient still needs to lose another 15 pounds.”Another example would be: “Patient chose not to pursue treatment” vs. “Patient refused treatment.” 11. Avoid subjective comments regarding the patient’s appearance or manner. 12. Plan ahead for 2023: • Staff task notes will also become accessible to patients. Start training practice staff to keep any subjective comments out of written communication. • Interoperability requirements for EHRs will include mobile devices like cell phones or the Apple Watch. During the worst of the COVID pandemic, numerous public opinion surveys showed that doctors were the most trusted source of information, topping government agencies, politicians, and the news media.4 While there are always certain to be outliers, it’s evident that access to clear, concise information builds patient trust and understanding. The editing process: or lack thereof One of the biggest changes to the rules that govern dissemination of information to patients electronically is the immediacy required. The rule now in effect says that patients must be able to access information in their medical records “without delay.” While there is no requirement for adapting notes to the ‘open note’ style, many physicians are choosing to use less ‘medical speak,’ including fewer abbreviations and technical terms, so that patients are readily able to understand and digest the information provided to them. One of the hardest pieces of getting used to this open-format communication style is how to address sensitive topics, such as diagnoses of serious illness, weight management, and/or mental health concerns. Surprisingly, some patients have reported that they appreciated direct language used in their notes, and that it helped them take their health more seriously. Clinicians in one study found that when some patients read visit notes about obesity or substance abuse, they were more motivated to attempt difficult behavioral changes. Some patients reported that “seeing it in black and white” made it more real.5 The Doctor’s Company outlines 12 strategies for successful open note-taking 12 Strategies for a Smooth Transition to Open Notes (CONTINUED ON PAGE 16)
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