FEATURE
( continued from page 25 ) education . Teach providers what information will be shared when , and how to provide context to their patients . Advise patients verbally and in writing that results may seem puzzling or abnormal , and that the practice will be reaching out separately for results that require discussion . Explain to patients that X-ray and pathology reports may include differential diagnoses not applicable to the individual , but included for completeness in physician review . Patient tip sheets , alerts and disclosures in the patient portal and after-visit summaries are valuable tools . Remind patients that results are posted rapidly , generally prior to their clinician ’ s review . Ask them to wait a couple days to open ; messages that explain and plan the next steps should appear .
EXCEPTIONS TO SHARING : Patient health care data should be available immediately , 5 unless conditions meet the clinical and technical exceptions provided in the Final Rule . 3 According to the federal Office for Health Information Technology ( ONC ), a provider ’ s practice that does not meet exception conditions does not automatically violate information blocking rules and is evaluated on an individual basis . 6 I have highlighted three general categories .
PREVENTING HARM : The ONC Final Rule provides an exception to releasing information to patients when it is reasonably likely to endanger the life or physical safety or cause substantial harm to the patient or another person . 3 Some EMRs enable providers to elect to block the release of certain data if this exception is met . It is recommended always to document the reason if this step is taken . 6
PRIVACY AND SECURITY : This exception is applicable if disclosing health information is prohibited under state or federal privacy laws . Remember , once medical information is sent to an application , it is only as secure as that application or device . 6
EXCEPTIONS BASED ON PRACTICE OR ORGANIZATION CLINI- CAL APPLICATIONS ( INFEASIBILITY , CONTENT AND MANNER EXCEPTIONS ): There are several exceptions related to the actual
IT capabilities available . The patient should be given every opportunity to receive health care data electronically . These exceptions are complex but help address practices without an IT solution build that enables full compliance . In these cases , patients must be offered a satisfactory alternative . 6
OPEN NOTES : SHARING CLINICAL NOTES WITH PATIENTS
Sharing of clinical notes is now mandated and should be available to release immediately to patients electronically . 4 Implementing this form of transparency has gained momentum over the last decade , after noting significant benefit from improved patient trust along with better patient compliance with medical plans . 13 Eight note categories are specifically included : consultation , discharge , history and physical , imaging , laboratory , pathology , procedure and progress notes . Psychotherapy notes and notes that may be used in civil , criminal or administrative action may be excluded and often termed “ sensitive ” in EMRs . 5
NOTE WRITING TIPS FOR CLINICIANS :
In general , note writing by clinicians need not change significantly despite immediate sharing . Surveys have shown that patients understand and reasonably expect provider notes to be written in medical terms that may be difficult for them to interpret . Often , according to data compiled by OpenNotes . org , patients will communicate corrections to their chart , but 96 % had little difficulty understanding notes overall . Still , clinicians may want to explain that their notes include medical jargon meant also for other professionals to interpret efficiently , and that any questions may be addressed later . Our note styles should adapt slightly to avoid commonly misunderstood terms , with awareness that they will be read so quickly . 14 , 15 . Research has shown that sharing notes with patients has improved patient care . Specifically , patients are more engaged , are better prepared for visits , better understand their conditions and have better relationships with their doctors . Practices have seen improvements in patient satisfaction overall . 17
NOTE WRITING STYLE CONSIDERATIONS
It ’ s recommended that notes should be positive and supportive in tone , being careful to avoid usages that may be considered critical or offensive . Be mindful of how sensitive clinical and mental health content is documented . Providers should take special care only to document items discussed with the patient and performed ( avoid macros that include extensive ROS or complete PE findings that were not actually performed ). See the suggestions that I have collected in the table below . 15
TABLE 1 PATIENT-CENTERED NOTE SUGGESTIONS
Potentially offensive or negative
PT , Case manager , provider or team refuses to see patient
Morbidly obese
SOB
Patient is belligerent , threatening , paranoid , etc .
Patient refuses ( negative , confrontational tone )
Non-compliant ( assumes intent )
FU
Consider different language or explanation
Omit from medical record if not patient related or re-word - not the place to voice frustrations
BMI > 30 or obese per medical criteria
Shortness of breath or SOA
Consider relevant patient quotes , uncooperative ( reason ?). Use simple quotes without statements that may seem to relay judgment
Declines , or if refuse used , give patient stated reason ( fatigue , nausea , etc .)
Non-adherent ( include reason )
Follow up
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