Educating Medical Trainees About Patient-Centered Documentation in the Time of Open Notes.

Area of Science:

• Medical Education
• Health Communication
• Digital Health

Background:

• Open notes grant patients direct access to clinical documentation in electronic health records.
• This shifts documentation from administrative use to direct patient communication.
• Relationship-centered care emphasizes the quality of interactions among patients, clinicians, and care teams.

Purpose of the Study:

• To highlight the significance of clinical documentation language and tone in relationship-centered care.
• To advocate for training health professional students in patient-centered documentation.
• To underscore the impact of documentation on the patient-physician relationship and patient experience.

Main Methods:

• Analysis of the evolving role of clinical documentation with the adoption of open notes.
• Examination of the principles of relationship-centered care and its implications for documentation.
• Discussion of the impact of language and tone in clinical notes on patient engagement and therapeutic alliances.

Main Results:

• Clinical documentation is now a form of patient communication, influencing the patient-physician relationship.
• Inclusive, respectful documentation strengthens the therapeutic alliance and affirms patients' roles.
• Biased or judgmental language can undermine relationships and negatively impact health outcomes.

Conclusions:

• Patient-centered documentation is crucial for advancing relationship-centered care.
• Training in empathetic, unbiased documentation is essential for health professional students.
• Effective documentation improves both patient and clinician experiences and strengthens the therapeutic alliance.