Vanka A, Johnston KT, Delbanco T, et al. Guidelines for Patient-Centered Documentation in the Era of Open Notes: A Qualitative Study. JMIR Medical Education. 23/11/2024:59301 (forthcoming/in press). DOI: 10.2196/59301
doi: https://preprints.jmir.org/preprint/59301/accepted
This study, titled “Guidelines for Patient-Centered Documentation in the Era of Open Notes: A Qualitative Study,” (Vanka, et al) explores how clinicians can write medical notes in ways that respect and empower patients. Prompted by the 21st Century Cures Act’s mandate for transparent access to medical records, the research involved focus groups comprising patients, experienced clinicians, medical educators, and resident physicians. Using an iterative thematic analysis, researchers distilled 10 core principles for creating patient-centered documentation. These include using respectful, person-first language, verifying past medical information to avoid errors, and avoiding acronyms or phrases that could convey judgment or bias. The findings also emphasize sensitivity to language around physical exams, trauma histories, and diagnostic uncertainties, underscoring the value of clear, collaborative communication in notes.
The study’s recommendations are particularly relevant for teaching medical students and early-career clinicians. By integrating these guidelines into medical education, the authors aim to normalize inclusive and empowering documentation practices that strengthen patient-clinician relationships and improve patient engagement. While recognizing limitations in sample diversity and potential resource demands for widespread adoption, the study provides a foundational framework for thoughtful, patient-centric documentation that can evolve with further research and feedback. Read the paper.
