Notes at your fingertips: Open note considerations regarding pediatric and adolescent care.

Area of Science:

• Health Informatics
• Medical Ethics
• Pediatric Care

Background:

• The role of clinician notes is expanding to include patients and guardians.
• The OpenNotes initiative and the 21st Century Cures Act mandate electronic access to clinical notes.
• Pediatric care introduces specific challenges in maintaining confidentiality with increased note accessibility.

Purpose of the Study:

• To explore the challenges and considerations of implementing open notes in pediatric settings.
• To identify the need for technological solutions and workflow adaptations for compliance and confidentiality.
• To address the evolving communication and documentation styles required for transparency and shared decision-making.

Main Methods:

• Review of existing literature on OpenNotes and patient access to medical records.
• Analysis of the implications of the 21st Century Cures Act Information Blocking Rule.
• Discussion of unique challenges in pediatric and adolescent patient care regarding confidentiality.

Main Results:

• Increased patient access to notes offers benefits but presents unrealized drawbacks, especially in pediatrics.
• Statewide variability in privacy protections creates a technological gap for consistent clinician support.
• Further research is needed on workflow impacts across different care settings and institutions.

Conclusions:

• Adapting note-writing to be patient-understandable is crucial for engagement and shared decision-making.
• Clinician communication and documentation styles must evolve with increasing transparency in medicine.
• Education and training are essential for clinicians to navigate open notes while ensuring compliance and patient confidentiality.