References

  1. Walker J, Leveille S, Bell S, et al. OpenNotes after 7 Years: Patient experiences with ongoing access to their clinicians’ outpatient visit notes. J Med Internet Res. 2019;21(5):e13876. Published May 6, 2019 [published correction appears in J Med Internet Res. 2020 Apr 30;22(4):e18639].
  2. DesRoches CM, Leveille S, Bell SK, et al. The views and experiences of clinicians sharing medical record notes with patients. JAMA Netw Open. 2020;3(3):e201753. Published March 2, 2020.
  3. Fernández L, Fossa A, Dong Z, et al. Words matter: What do patients find judgmental or offensive in outpatient notes? J Gen Intern Med. 2021 Feb 2. doi: 10.1007/s11606-020-06432-7. Epub ahead of print. PMID: 33528782.
  4. Klein JW, Jackson SL, Bell SK, et al. Your patient is now reading your note: Opportunities, problems, and prospects. Amer J Med. 2016;129(10): 1018-1021.

Issue

Topic

Clinical Practice, Health Policy & Advocacy, Medical Education, Medical Ethics, SGIM, Social Determinants of Health

Author Descriptions

As physicians, we have become unwilling participants in the documentation burden, both creating and bemoaning “note bloat.” We have used note templates, cut and paste, etc. to meet unreasonable and anachronistic expectations. We hope that this summary guides SGIM members in preparing notes that are not only less burdensome and more useful for the next clinician, but most importantly, for the patient.

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