Clinical ethics consultation documentation in the era of open notes

Area of Science:

• Medical Ethics
• Health Informatics
• Patient Advocacy

Background:

• The 21st Century Cures Act mandates real-time patient access to clinical notes, termed "open notes."
• Open notes aim to enhance transparency and trust in the clinician-patient relationship.
• This legislation introduces complexities regarding the content of clinical notes.

Purpose of the Study:

• To explore the implications of open notes on clinical ethics consultations.
• To review current documentation styles for clinical ethics consultations.
• To provide recommendations for documenting ethics consultations in the era of open notes.

Main Methods:

• Exploration of the impact of real-time patient access to clinical notes on ethics consultations.
• Review of existing practices and styles for documenting clinical ethics consultations.
• Development of recommendations for future documentation practices.

Main Results:

• Open notes necessitate a re-evaluation of how clinical ethics consultations are documented.
• Documentation must balance the needs of healthcare professionals with patient accessibility and sensitivity.
• Sensitive topics discussed in ethics consultations require careful and ethical documentation.

Conclusions:

• Clinical ethics consultation notes must now be crafted with dual audiences in mind: clinicians and patients.
• Recommendations are provided to ensure documentation is ethically robust, accurate, and sensitive.
• Adapting documentation practices is crucial for maintaining effective ethics consultations under open notes.