This is an update to our blog: Sharing Notes with Patients – What Physicians Need to Know
Good medical record keeping is essential for the delivery of quality healthcare and to support communication between different healthcare professionals. With the widespread adoption of electronic health records (EHRs), outsourcing medical transcription is a practical strategy to ensure efficient medical record management. Partnering with an experienced medical transcription company can ensure proper documentation of the medical history of the patient, easing the documentation task for nurses and physicians, improving their workflow efficiency, and allowing them to spend more time with patients.
The use of personal health records (PHRs) has increased with rising mobile device use and improvement in patients’ technical abilities. PHRs are integrated with EHR systems. An April 2021 provision of the 21st Century Cures Act, patients can freely access all of their electronic medical record chart notes. Patients have access to the following parts of the electronic medical record:
- consultations
- progress notes
- discharge summaries
- history and physicals
- imaging narratives
- lab reports
- pathology reports
- procedure notes
Psychotherapy notes are not subject to disclosure under the Final Rule.
Benefits of Sharing Medical Records with Patients
The American Medical Association (AMA) strongly advocates open notes. Studies have found that shared visit notes, also called open notes, increase transparency in care and also have the potential to enhance provider-patient trust and treatment adherence. The first large-scale survey of patient experiences with a broad range of physicians, nurses, and other clinicians working in practices which shared notes reported that patients considered note reading very important for managing their health and share their notes frequently with others. The study was published in the Journal of Medical Internet Research (JMIR) in 2019.
Let’s dive into the top benefits of sharing medical notes with patients:
- Enhances patient’s understanding of their health information: It helps them help better understand their doctor’s recommendations, which will help them take actions required for their health, and/or make appropriate health decisions. For instance, in radiology, a well-formatted report with structured information and clear content display including patient summaries, and infographics, can greatly improve patient understanding and inclusivity.
- Reminds patients of what was said at the visit: According to a study from Brown University’s School of Public Health, regardless of their level of educational attainment, patients only remember about 49% of the decisions and recommendations made during discussions with their doctors, and about 15 percent of the information was remembered erroneously or not at all. “As stress of that visit increases, the amount that they remember decreases,” says Catherine DesRoches. Executive Director at OpenNotes. The Brown University study found that prompting helped recall another 36 percent of it. So, seeing their notes can help patients better understand and recall what was discussed at the visit.
· Improves treatment adherence: Sharing notes with patients can help them follow their treatment regimens properly. When patients read their notes and understand why a medication is prescribed, it is more likely that they will take that medication as prescribed. It could also prevent problems like not filling or refilling a prescription, taking the wrong dose, taking a medication at the wrong time, and not recognizing the effects of inappropriate dosing, side effects or drug interactions.
A study published in the Annals of Internal Medicine suggested that that medication adherence improved with shared clinical notes (patientengagementhit.com). With access to their clinician notes:
- 64% or patients said they better understood why their clinician prescribed a certain medication
- 62% felt more in control of their medications
- 57% said they were able to find answers to questions they had about their medications
- 61% said access to clinician notes made them feel more comfortable taking their medications
The study showed even greater benefits for patients who do not primarily speak English or who have lower health literacy scores. Family members or others could help them review and interpret the key points made in notes in their homes.
· Promotes shared decision-making: In addition to supporting treatment adherence, giving patients access their medical chart improves communication and promotes shared decision making. By reading their medical notes, patients can get a better idea of the physicians’ thinking, the pros and cons of different types of treatment, and the feasibility of medical choices. This will also improve patients’ confidence in managing their health.
- Informs patient caregiver: Access to notes by family members and caregivers will help them better collaborate with clinicians and provide better care. Providing access to information about the patient’s diagnoses, test results, and prognosis would allow caregivers to give clinicians insights into the patient’s symptoms or behaviors, needs and preferences, which is important for effective support.
- Helps detect errors and improves safety: When patients read their notes, they may detect mistakes that are clinically significant. Among very serious errors identified by patients, the most common were mistakes observed were in diagnoses, medical history, medications, physical examination, test results, notes on the wrong patient, and sidedness, according to a JAMA study published in 2020. When patients report these mistakes, it can improve record accuracy and patient engagement in safety.
- Increases trust: In the AMA STEPS Forward podcast on sharing clinical notes with patients,” co-founder of OpenNotes Tom Delbanco, MD, said, “Even when patients don’t read their notes, just knowing that the note is available, increases their trust in their provider and in the organization where they’re getting the care”. This is especially important during a health crisis like the COVID-19 pandemic when public trust in physicians and medical science waned.
As open notes are a legal requirement, clinicians should pay attention to the quality of the information and its timeliness. Medical transcription services can play an important role in this context. To motivate patients to use the medical information in their record, reports must also be patient-friendly and jargon-free. For instance, the current drive to create patient-centered, interactive radiology reports provides a unique opportunity for radiologists to understand the needs of patients directly, and for patients to effectively communicate their health information (www.medicaleconomics.com). Radiology transcription services are available to support radiologists in their efforts to provide quality radiology reports for patients and referring providers.
