Have you ever accessed your doctor’s notes after a visit? Did you even know you could?
Since April 2021, the 21st Century Cures Act has required health care providers to allow patients access to all of their medical and clinical records, including clinician notes. But even a decade before the act was passed, there had been a clinician-led movement to make notes available and accessible to patients. Tom Delbanco, MD, and Jan Walker, RN, MBA, co-founded OpenNotes with simple calculus, allowing and encouraging patients to see their notes to improve transparency, incentivize more patient-centered care, and encourage patients to play an active role in their health. The initial results of their pilot program showed around 80% of patients found reviewing their notes helpful and empowering, improving patient-provider relationships across the board. The pilot was popular among clinicians as well. Even after the program had concluded, all participating clinicians continued making notes available to their patients despite initial skepticism.
The movement has grown rapidly. Today, more than 150 million patients across the U.S. have the ability to view their “open notes.” In late 2020, Dr. Delbanco approached leadership at Harvard Medical School about incorporating note-taking into the curriculum. At that time, Anita Vanka, MD, was co-directing the first-year clinical skills course, teaching students foundational skills like taking patient histories and completing physical exams.
“We knew this would be a great opportunity to teach learners, from the start, how to thoughtfully write a medical note,” said Dr. Vanka. “We wanted to instill the importance of writing patient-centered notes so that they were establishing a strong connection with their patients right away.” Along with her co-director, Dr. Katherine Johnston, Dr. Vanka set out to create a comprehensive curriculum based on patient-centered documentation practices—one that the Macy Foundation was thrilled to support.
Coursework & Best Practices
Dr. Vanka and the team spent eight months developing the curriculum before deploying it to first-year medical students. After extensively reviewing literature and the work of OpenNotes, Dr. Vanka knew they would need to establish best practices to guide students.
The team gathered focus groups composed of patient advocates and physicians familiar with open notes, medical educators who taught clinical skills, and resident physicians with an interest in medical education. The process began with a standard questionnaire to stakeholders asking questions such as:
What would you be teaching medical students?
What are words that you might find harmful or stigmatizing and why?
What does patient-centered language mean to you?
Based on these focus groups, the team created a list of best practices for note-taking:
Checklist of Best Practices in Patient-Centered Documentation: Major Themes
- Use person-first language.
- Refer to your patients as how they want to be identified.
- Avoid abbreviations and acronyms, especially if not officially approved by the practice.
- Say what you write, write what you say.
- Verify past history information before recording it in the note.
- Avoid words that may convey bias or judgment.
- Keep physical exam descriptions objective.
- Empower your patients with encouraging words and clear next steps.
- Pay close attention to sensitive topics, including but not limited to sexual history, trauma history, substance history, mental health, or illness.
- Write from your perspective.
“The traditional model of medical care was that the clinician would focus on the diagnosis and treatment, while the patient was a passive third party in the conversation,” said Dr. Vanka. “The best practices for documentation may seem obvious, but we found that highlighting them in a simple checklist was incredibly powerful and helped clinicians focus on the high-quality patient-centered care they strove to deliver.”
The first-year curriculum launched with a two-hour workshop that students would attend before seeing a patient or writing a note to catch them at the very beginning of their learning process. Prior to the workshop, students watched an overview of OpenNotes, which included clips from interviews with patients and providers describing their experiences. The workshop itself started with a reflection for students—have they ever read their own clinical notes or those of a family member? How did they respond? The instructions of what specifics go into writing a medical note followed, and students were introduced to the best practices checklist. Each best practice was expanded on, and examples were provided before students graded a clinical note and discussed what they would change and why.
Patient-Centered Care & Language
Dr. Vanka and team also hosted a session for faculty preceptors (those grading student notes and giving feedback), who often weren’t well-versed in writing patient-centered notes.
“Aligning language with care is the name of the game,” said Dr. Vanka. “Collaboration with patients ensures they have agency and can take part in the decision-making aspect of their own health care while simultaneously building trust with their providers.”
There are a few traditional examples of language in the medical field that have negative connotations such as “chief complaint” (the reason for a doctor’s visit), “patient is combative,” or “patient is non-compliant.” This is common medical lingo for health care providers but can be alarming for patients to read about themselves or their loved ones. Teaching students to use neutral verbs and phrases such as patient states, tells me, reports, etc., versus patient claims, complaints, or denies, can make a world of difference.
Before students go on to their core clinical year, they return to Dr. Vanka and the team for a one-hour workshop to review recently written notes and review what could be improved based on the best practices checklist.
The second half of the workshop then focuses on what they call “upward feedback,” something that will likely need to happen in the field as they encounter resident and attending colleagues who may approach writing clinical notes differently.
“We try to empower students to encourage change in how their colleagues write notes by grounding their feedback in curiosity, asking open-ended questions like ‘I’m curious why this was written this way. I’m just trying to understand,’ or even referencing the curriculum as a starting point,” said Dr. Vanka. “For example, saying we were taught in our first year that if we use this word in a note, it may affect the patient in a different way than it affects us.”
Approaching colleagues in this manner helps residents avoid giving critical feedback and sparks more thoughtful conversations in the workplace.
For second-year students, the program dives deeper into nuances around more sensitive issues with open notes. For instance, how do you write notes when you have a patient with a mental health condition or include details on gender and sexual identity? To help learners with these questions, the project team created a series of podcasts of both audio and visual interviews with an OpenNotes team member—bioethicist Stephen (Steve) O’Neill, LICSW, BCD, JD—who interviews experts in these content areas to share professional insight. So far, the team has developed 14 episodes on an array of sensitive topics that students can access as they go through their rotations.
Project Success & What’s Next
Last year, Dr. Vanka and team co-authored A Patient-Centered Documentation Skills Curriculum for Preclerkship Medical Students in an Open Notes Era, published in MedEdPORTAL—one of the journal’s top 10 most-downloaded publications of the year. And just last month, Dr. Vanka and team published Guidelines for Patient-Centered Documentation in the Era of Open Notes: Qualitative Study in JMIR Medical Education.
The project team is currently building a consortium of other medical school student leaders to provide feedback and insight on the best practices list based on their own experiences. While this course has been solidified in the Harvard Medical School curriculum, Dr. Vanka plans for the course to expand to other schools so that it can be studied at a larger scale. It also has the potential to be turned into a required competency or entrustable professional activity, as deemed by the American Association of Medical Colleges (AAMC), to measure students nationally on their ability to write patient-centered notes. The podcast series could eventually be published as well, to help students outside of Harvard Medical School implement thoughtful note-taking.
“The momentum of our work shows that just because open notes now exist for all of our patients doesn’t mean the work is done. How do we teach our students, residents, and faculty?” said Dr. Vanka. “We’ve only just started chipping away at this, but the enthusiasm among learners is real and inspiring.”
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