As the push for transparency in health care grows, shared visit notes are becoming more common. Shared notes can enhance communication and engagement among patients, physicians, and family members and can be an important facilitator of shared decision making.
To prepare for increased transparency, physicians can take simple steps to modify their documentation:
1. Be consistent and transparent. What you put in the note should reflect your communication in the office. There should be no surprises.
2. Minimize jargon and abbreviations that patients might easily misinterpret, and simplify medical terms where possible. For example, say “short of breath” rather than SOB or dyspneic.
3. Highlight patients’ strengths and achievements in addition to their clinical problems, particularly for mental health issues. For example, when documenting a patient’s depressive symptoms, note encouraging findings as well, such as “Patient has joined a walking group.”
4. Describe behaviors rather than labeling the patient or making judgments. For example, instead of saying “Poor historian,” say “Patient could not recall.”
Read the full FPM article: “Sharing Visit Notes: Getting Patients and Physicians on the Same Page.”
Sign up to receive FPM's free, weekly e-newsletter, "Quick Tips & Insights," featuring practical, peer-reviewed advice for improving practice, enhancing the patient experience, and developing a rewarding career.