Why Are Patient-Friendly Notes Important for Improving Patient-Provider Relationships?
The patient-provider interaction has evolved into the bedrock of quality healthcare. Patients now have access to their electronic health records according to the 21st Century Cures Act (EHR). According to numerous studies, giving patients access to their medical information might inspire them to cooperate with their providers and become active participants in their own treatment.
While medical transcription services can assist physicians in ensuring accurate and timely EHR documentation, creating patient-friendly notes is crucial for establishing trust and knowledge, as well as improving the patient-provider relationship. Furthermore, physician language in patient health records can influence the quality of treatment that patients get along the continuum of care.
Advantages of EHR Patient Access:
Giving people easy access to their personal health information can help patients and doctors communicate more effectively. According to the Cures Act Final Rule, providers must be able to make eight types of information free of charge available to all patients:
• Notes from the consultation
• Notes on Discharge Summary
• Physical and historical
• Narratives about images
• Narratives for laboratory reports
• Narratives from pathology reports
• Notes on Procedure
• Notes on Progress
As a result, patients now have electronic access to a wide range of their medical data as well as physician notes.
Many studies have demonstrated that open notes lead to greater results. According to a research published in the Journal of General Internal Medicine in May 2021, 50 percent of doctors who tested clinical notes for the first time discovered that their patients took better care of themselves when provided access. Approximately three-quarters of clinicians reported increased patient empowerment.
The physician-patient connection is built on trust, knowledge, regard, and loyalty. According to research, the patient-provider relationship is critical to quality care. Sharing visit notes can improve patient-provider satisfaction in a variety of ways:
• Patient education has been improved.
• Patient engagement and empowerment have improved.
• Patients have a better understanding of their treatment programmes and become active participants in their care.
• Patients who have access to their healthcare visits, test results, and treatment history are better able to control their own health.
• Improves medication adherence and doctor visit follow-up
• Can lead to medical error detection and correction, contributing to enhanced patient safety.
• Enhances patient outcomes
However, the success of the Open Notes method is contingent on producing "excellent" open notes in order to provide a great patient experience.
What exactly are "Good" Open Notes?
Empathy, open communication, and shared decision-making are essential components of an effective patient-provider relationship. According to PatientEngagementHIT, open clinical notes that are empathic, informed, and rely on objective clinical facts are more likely to result in a positive patient experience.
Although the new law does not require physicians to change their note-writing style, the American Academy of Family Physicians (AAFP) notes that some minor changes can be beneficial, especially when documenting potentially sensitive topics such as mental health, obesity, substance use disorder, sexual history, or spousal abuse. According to the AAFP, patient-friendly notes should have the following four characteristics:
Transparency: The note should represent the physician's in-office conversation with the patient. "There should be no surprises," the AAFP says.
Use of jargon and abbreviations to a minimum: Patients are likely to mistake sophisticated medical jargon. Such terms should be defined briefly or simplified. Here are some instances of similar phrases: blood profile - a collection of blood tests; bradycardia - a sluggish heartbeat; idiopathic - caused by an unknown factor; subcutaneous - beneath the skin and prognosis (outlook, likely consequences). Patients and family members can be affected by derogatory terminology in patient notes.
According to a 2021 JAMA network article, clinicians should be more cognizant of stigmatising language in patient records in order to ensure that their notes are helpful and respectful.
Highlight both the patient's issues and his or her talents and accomplishments: This is especially significant in mental health records because it provides patients with a clear picture of their illness as they deal with tough behavioural changes.
Describe behaviours without labelling or judging the patient: It is critical to use positive words rather than judgmental language. According to the JAMA network study, positive language was used in patient notes more frequently and explicitly, including: (1) direct compliments, (2) expressions of approval, (3) expression of the physician's own positive feelings toward the patient, (4) blame minimization, (5) personalization, and (6) highlighting patient authority for their own decisions. Negative wording in patient notes, according to the researchers, has the ability to convey bias and impair the quality of care that patients receive later.
How a Medical Transcription Service Can Assist?
Over the last decade, this practise innovation, known as 'open notes,' has grown rapidly, and today, more than 50 million patients in the United States are allowed access to their clinical notes," wrote OpenNotes leaders in the Annals of Internal Medicine. With healthcare difficulties such as an ageing population, an increasing number of patients with chronic diseases and comorbidities, and the outbreak of infectious diseases such as COVID-19, physicians are constantly under pressure and limited in their time to manage a greater workload.
Providers can enhance their relationship with patients and achieve better outcomes by allowing them to become actively involved in their own care. Medical transcription outsourcing can help the open notes revolution by assuring timely, error-free patient records, letting doctors to focus on treatment, and freeing up internal resources for other essential activities.
In conclusion, patient-friendly notes play a pivotal role in transforming healthcare interactions. By adopting clear and accessible documentation, healthcare providers can strengthen their patient relationships and foster a more positive care experience.
With advancements in technology, solutions like iTranscript360 can streamline the process further, ensuring seamless communication and improved patient outcomes. Embracing patient-friendly notes is not only a step towards better care but also a testament to the commitment of healthcare providers in putting patients at the center of their practice.