Using Patient Quotations in Chart Notes: A Clinical Ethics Perspective.

Area of Science:

• Healthcare Policy
• Clinical Ethics
• Health Informatics

Background:

• The 21st Century Cures Act, enacted in 2021, includes the OpenNotes directive.
• This directive mandates that patients and their representatives must have real-time access to electronic medical records.
• This policy shift necessitates a review of current clinical charting practices.

Purpose of the Study:

• To analyze the risks and benefits of quoting patients directly within electronic medical records under OpenNotes.
• To provide guidance for clinical ethicists on how to address charting practices related to patient quotations.
• To promote more reflective and ethical charting behaviors among healthcare teams.

Main Methods:

• Discussion of risks and benefits associated with direct quotations in clinical notes.
• Exploration of the implications of OpenNotes on patient record access.
• Identification of strategies for clinical ethicists to mitigate potential harms of quoting patients.

Main Results:

• Direct quotations, while seemingly clear, may carry inherent risks in patient record documentation.
• The OpenNotes policy presents both challenges and opportunities for improving clinical communication and documentation.
• Clinical ethicists can play a crucial role in guiding teams toward more thoughtful charting.

Conclusions:

• Reflective charting practices are essential, especially concerning the use of patient quotations under OpenNotes.
• Ethicists can proactively guide healthcare teams to navigate the complexities of patient record access and documentation.
• Balancing transparency with patient privacy and accurate representation is key in modern clinical documentation.