Open Notes and Transparency

Is the transparency inherent in open charts conducive to Healthy Survivorship?

In most contexts, transparency is considered a virtue. But increasing transparency can have unintended negative consequences, too. WIth this in mind, let's look at two challenges physicians face in the setting of open notes.

Medical jargon can have derogatory connotations in social settings. For example, clinicians today use the term "obese" as medical shorthand for "at least 20-30% above average weight for their height, age, and sex" (from Taber's Cyclopedic Medical Dictionary). Patients reading their chart might be offended by the term "obese." Others might conclude their physicians are making judgments about their character. Patients' anger, shame or embarrassment could jeopardize the clinician-patient bond.

Detailed differential diagnoses serve clinicians, not patients. Physicians routinely record the many possible diagnoses for a problem, including serious problems that are highly unlikely. Patients reading their chart might freak out after learning about diseases that weren't even on their radar. Patients' distress can jeopardize the clinician-patient bond and create obstacles to Healthy Survivorship.

I believe clinicians can find ways to write their notes in ways that are less likely to cause problems for patients who read the notes, without jeopardizing the value of the notes to clinicians. It will take creativity and effort, but it can be done. 

My bigger worry is the apparent conflict between sharing chart notes and delivering compassionate care, as I'll discuss in my next post.

Comments

[healthy life is my choice]

nice post, thank you

[Jonnie Hickman]

I am a nurse and a patient and I have to say that after I reviewed my medical records the first time, I was insulted by some of the things that were written in my chart by my primary physician of 12 years. My recall of the appointments were not the same as hers, yet my views were not charted. I felt like she is the doctor, so why would anyone care what I thought happened in the appointment? In each interaction there are two different accounts of it.

For an example, I went in to have a pre-employment physical. I had the job, just needed to pass the health part. My doctor told me that she didn't feel comfortable releasing me to work without the reports from Mayo Clinic in the chart. I had no insurance because I had left my previous job without COBRA, so I paid for the appointment in full. The reason I was at the doctor was for her to sign a physical so I could return to work. A year later when I saw my chart it said that I came in for a physical and I told her I wasn't well enough to work. I was insulted. A 12 year bond was broken. All I wanted to do was go back to a normal exsistence.

This made me stop and think of the things that I had charted about patients over the years. How many times my patient load was too much. How many things that I may have charted wrong or in haste that if my patients would have read they would have felt betrayed too.

I am not a doctor, but as a nurse I was sometimes called to be the eyes and ears of the physician I worked under and I agree that we should all take a little more time to consider the words that we put down in a chart that may follow around a patient for their lifetime.

Thank you.

[Wendy S. Harpham, M.D.]

Dear Jonnie,

I'm sorry to read of your experiences.

Charting should be dispassionate, yet the material is so highly charged from the patient's perspective that the potential to disrupt or destroy clinician-patient bonds is great.

As you'll see when I wind down this series, some good can -- and must! -- come out of the development that patients may read their charts.

With hope, Wendy

[Jonnie Hickman]

Yes Dr Wendy and I look forward to the rest of this series. As a nurse, I was able to understand better the language and the way and order of the chart. The diagnoses, some of the methods of the facilities and doctors were clearer from a medical background. A patient though without the medical schooling could be very hurt and confused by the terms and ways of medical jargon.

Thank You!

[Wendy S. Harpham, M.D.]

Dear Jonnie,
We are in an era of transition. Many patients today are now comfortable with medical terminology related to their disease and treatment because patient-centered resources are available: support groups, books, articles, newsletters and web-based resources. It is just one more step to help patients learn the vernacular found in physicians' notes.
With hope, Wendy