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Patients Evaluate Visit Notes Written by Their Clinicians: a Mixed Methods Investigation
Suzanne G Leveille1,2,3, Patricia Fitzgerald2, Kendall Harcourt2
1College of Nursing and Health Sciences, University of Massachusetts, Boston, MA, USA.
Journal of General Internal Medicine
|July 17, 2020
Summary
Patients largely understand their open notes and find them accurate. However, poor understanding or inaccuracies reduce patient confidence and willingness to recommend clinicians, highlighting areas for improvement in clinical documentation.
Area of Science:
- Health Informatics
- Patient Engagement
- Clinical Communication
Background:
- Patient involvement in care correlates with improved health outcomes.
- Open notes, or patients accessing their clinical visit notes online, are increasingly common.
- Understanding of these notes by patients remains largely unexamined.
Purpose of the Study:
- To evaluate patient perceptions of clarity, accuracy, and completeness of open notes.
- To gather patient suggestions for improving clinical note quality.
- To explore the link between patient understanding of notes and their likelihood to recommend clinicians.
Main Methods:
- An online survey was distributed to patients across three large health systems.
- Data were collected from June to October 2017.
- A mixed-methods analysis was performed on responses from 21,664 adult patients who had read an open note within the past year.
Main Results:
- Nearly all patients (96%) reported understanding their notes well.
- A high percentage (93%) found the notes accurately described their visit.
- Common improvement suggestions focused on note structure, content, jargon, and accuracy; poor understanding or perceived inaccuracies significantly decreased clinician recommendation likelihood.
Conclusions:
- Patients generally understand and trust their open notes, with minimal sociodemographic disparities.
- Patients offer valuable feedback for enhancing note quality, particularly regarding clarity and accuracy.
- Addressing comprehension and accuracy issues in open notes is crucial for maintaining patient trust and positive clinician relationships.
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