Guidelines for Patient-Centered Documentation in the Era of Open Notes: Qualitative Study

Patients in the United States have recently gained federally mandated, free, and ready electronic access to clinicians' computerized notes in their medical records ("open notes"). This change from longstanding practice can benefit patients in clinically important ways, but studies show some patients feel judged or stigmatized by words or phrases embedded in their records. Therefore, it is imperative that clinicians adopt documentation techniques that help both to empower patients and minimize potential harms.

At a time when open and transparent communication among patients, families, and clinicians can spread more easily throughout medical practice, this inquiry aims to develop informed guidelines for documentation in medical records.

Through a series of focus groups, preliminary guidelines for documentation language in medical records were developed by health professionals and patients. Using a structured focus group decision guide, we conducted 4 group meetings with different sets of 27 participants: physicians experienced with writing open notes (n=5), patients accustomed to reviewing their notes (n=8), medical student educators (n=7), and resident physicians (n=7). To generate themes, we used an iterative coding process. First-order codes were grouped into second-order themes based on the commonality of meanings.

The participants identified 10 important guidelines as a preliminary framework for developing notes sensitive to patients' needs.

The process identified 10 discrete themes that can help clinicians use and spread patient-centered documentation.