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Area of Science:

  • Mental Health Research
  • Health Informatics
  • Clinical Documentation

Background:

  • Open notes, providing patients digital access to clinical documentation, can enhance transparency and trust in mental health care.
  • Concerns exist among health care professionals (HCPs) regarding potential negative impacts on documentation quality.

Purpose of the Study:

  • To examine objective and subjective changes in clinical documentation after implementing open notes.
  • To assess the impact of open notes on documentation practices in psychiatric outpatient clinics.

Main Methods:

  • Analysis of 876 clinical notes (pre- and post-implementation) using 16 linguistic features.
  • Qualitative interviews with 10 psychiatric HCPs analyzed via reflexive thematic analysis.
  • Utilized Wilcoxon signed rank test for quantitative linguistic analysis.

Main Results:

  • Post-implementation, notes showed increased comprehensibility, resource-orientation, and emotional positivity, with decreased stigmatizing and demeaning language.
  • HCPs reported adapting documentation to be more patient-centered, using less jargon and more explanations.
  • HCPs experienced increased workload and time demands due to workflow adjustments for open notes.

Conclusions:

  • Open notes implementation leads to significant objective and subjective changes in mental health clinical documentation.
  • Findings suggest HCPs aim for more patient-friendly notes, potentially benefiting patients and the therapeutic alliance.
  • Sustainable open notes require efficient workflow integration and education for HCPs on patient-centered documentation.