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Guidelines for Patient-Centered Documentation in the Era of Open Notes: Qualitative Study
Anita Vanka1,2, Katherine T Johnston2,3, Tom Delbanco1,2
1Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States.
JMIR Medical Education
|January 20, 2025
Summary
Clinicians should use patient-centered documentation to empower patients and minimize harm, especially with new open notes access. This study developed 10 guidelines for sensitive medical record language.
Area of Science:
- Medical Informatics
- Patient Communication
- Health Documentation
Background:
- US patients now have federally mandated electronic access to clinician notes (open notes).
- While beneficial, some patients report feeling judged or stigmatized by record content.
- Patient-centered documentation is crucial to mitigate potential harms and empower patients.
Purpose of the Study:
- To develop informed guidelines for medical record documentation.
- To support open and transparent communication in healthcare settings.
Main Methods:
- Focus groups were conducted with 27 participants, including physicians, patients, and educators.
- A structured decision guide facilitated group meetings.
- An iterative coding process was used to identify themes from qualitative data.
Main Results:
- Ten important guidelines for documentation were identified as a preliminary framework.
- Themes were generated through grouping first-order codes into second-order themes.
Conclusions:
- The study identified 10 discrete themes for patient-centered documentation.
- These themes can guide clinicians in using and disseminating sensitive documentation practices.
Keywords:
21st Century Cures Actmedical student educationopen notespatient-centered documentation skillsMore Related Videos
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