What can clinicians do to ensure that chart notes are healing -- or at least not harmful -- to patients who choose to review them?
Clinicians can take some steps to make chart notes safer for patients:
1) When dictating or writing notes, clinicians can keep in mind that patients may read what is recorded.
2) When describing signs or symptoms, clinicians can use quotes of patients' descriptors. Clinicians can make efforts to avoid unnecessarily judgmental adjectives, adverbs and nouns.
3) When recording impressions, assessments and conclusions, clinicians can make efforts to distinguish facts from expectations from hopes.
4) When releasing records to patients, clinicians can provide a glossary of medical terms and acronyms.
5) Clinicians can provide opportunities for patients to ask questions, submit requests for corrections and voice concerns about the chart notes.
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