Guidelines for Patient-Centered Documentation in the Era of Open Notes: A Qualitative Study (Preprint)

BACKGROUND Patients have recently gained federally mandated, free, and ready electronic access to clinicians’ computerized notes in their medical records (‘open notes’). This change from longstanding practice can benefit patients in clinically important ways, but studies show some patients feel judged or stigmatized by words or phrases embedded in their records. Therefore, it is imperative that clinicians adopt documentation techniques that help both to empower patients and minimize potential harms. OBJECTIVE At a time when open and transparent communication among patients, families and clinicians can spread more easily throughout medical practice, this inquiry aims to develop informed guidelines for documentation in medical records. METHODS Through a series of focus groups, guidelines for language for documentation in medical records were developed by health professionals and patients. Using a structured focus group decision guide, we conducted four group meetings with different sets of 27 participants: physicians experienced with using open notes (5), patients accustomed to reviewing their notes (8), medical student educators (7), and resident physicians (7). To generate themes, we used an iterative coding process. First-order codes were grouped into second-order themes based on the commonality of meanings. RESULTS The participants identified 10 potentially important guidelines for developing notes sensitive to patients’ needs. CONCLUSIONS The process identified ten discrete themes that should help clinicians use and spread patient-centered documentation. CLINICALTRIAL N/A