Access to notes empowers adolescents to manage their health care with more independence and helps them learn to be more engaged in their own health.
See also Sharing Pediatric Notes
Who has access to the notes I write through the patient portal?
It depends on laws in your state. There are variations in how health care organizations and clinics implement parent and adolescent access policies for the portal. These often depend on state laws and technical capabilities in the electronic health record patient portal. Make sure you understand your institution’s portal access policies to understand who has access and how notes are made available in the portal.
OpenNotes: Sharing visit notes with patients and families | Pediatric Nursing (2018)
How do I make the most out of sharing adolescent notes?
Transition planning. Open notes can be a useful tool to help adolescents understand their health issues and become more engaged in their health care decisions and management. The notes can be incorporated as part of transition readiness, planning, and transfer to adult care.
Attitudes, experiences, and safety behaviors of adolescents and young adults who read visit notes: Opportunities to engage patients early in their care | Future Healthc J (2021)
What are the best practices when writing a visit note?
Best practices include:
- Ensuring that the note reflects what was discussed during the encounter
- Addressing patient and parent priorities and concerns
- Being respectful of patients/families and other care team members
- Practicing direct and transparent communication
- Using supportive language
- Addressing disagreements in a respectful manner
- Highlighting teamwork and emphasizing joint decision-making
- Avoiding judgmental, stigmatizing, and offensive language, such as:
- Personal descriptors
- “obese patient”, “anxious patient”
- Language that is critical
- “patient refuses”
- Language indicating distrust or disbelief of the information provided
- “patient claims”, “patient denies”
- Stigmatizing language and labels
- “non-compliant”, “drug-seeking”
- Understanding your institution’s policies on documenting confidential information shared by either the adolescent or parent and how to apply the 21st Century Cures Act Information blocking exceptions
- Personal descriptors
Words matter: What do patients find judgmental or offensive in outpatient notes? | J Gen Intern Med (2021)
How do I encourage my adolescent/young adult patients to understand and learn their medical history?
Here are a few best practices:
- When appropriate, encourage parents to review notes with the adolescent.
- Encourage discussion about notes.
- Make sure the note is available in a timely fashion.
- Incorporate and address patient and parent concerns in the notes.
- Encourage adolescents to speak up if they notice a mistake or inaccuracy in the note, or if the note doesn’t reflect what the adolescent remembers discussing during the visit.
- Acknowledge discrepancies, inaccuracies, and mistakes and update the note as appropriate.
OpenNotes: Toward a participatory pediatric health system | Pediatrics (2018)
What if an adolescent discusses a confidential issue during the visit?
Ideally, you can use confidential notes. For example, some health systems have created “confidential” note types that are hidden from the patient portal. Individual clinicians can elect to use this feature for information they do not want parents to access. They can also choose to create two notes (a note with only the confidential information, and one with general information), so that the parent/patient can access some pertinent information, i.e., the care plan. Alternatively, clinicians may create a single confidential note that will be completely suppressed from the patient portal.
Preserving privacy for pediatric patients and families: Use of confidential note types in pediatric ambulatory care | J Am Med Inform Assoc (2020)
