Perception versus reality: Does provider documentation behavior change when clinic notes are shared electronically with patients?

Richards, Sarah; Carlson, Kristy; Matthias, Tabatha; Birge, Justin

doi:10.1016/j.ijmedinf.2020.104304

Cited by 6 publications

(7 citation statements)

References 15 publications

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“…Health care systems affected by digital deceleration experience reduced efficiency; digitally hypervigilant individuals are prone to anxiety and overreaction in the face of change [ 5 ]. The parents in this study expressed anxiety in remarkably similar ways to health care staff in the same hospital—to the nervous clinicians identified during the Copying Letters initiative in the United Kingdom and the primary and specialist providers surveyed by Richards et al [ 34 ]. Like health care professionals, these parents express prospective worries—they “presuffer”—about exposing clinical notes to patients’ families before any notes have actually been released.…”

Section: Discussionmentioning

confidence: 59%

“…One parent pointed to the capacity of notes to reinforce and recapitulate information that had already been conveyed. Partridge [ 15 ] was originally motivated to copy letters to try and solve this very problem: “Parents and patients often do not remember accurately what doctors have told them.” The parents investigated by Richards et al [ 34 ] agreed—75% of the parents saying that the letter “reminded me what was said in clinic.” Recapitulation was the most frequently mentioned benefit by the 100 parents interviewed by [ 17 ], one of whom further validated this perspective when they said:…”

Section: Discussionmentioning

confidence: 96%

“…Early Copying Letters studies also mentioned jargon as a prospective fear among clinicians who cited this as a reason not to provide copied letters. They believed this, in part, out of concern that parents would not be able to understand medical language and, in part, because avoiding jargon because of a future patient reader would require the physician to "talk down" and degrade communication with other physicians, thus affecting the content and quality of the letters [ 34 , 35 ]. It is interesting that when this theoretical proposition was actually tested by researchers of Copying Letters, parents who had difficulty reading the notes appeared to be in the minority.…”

Section: Discussionmentioning

confidence: 99%

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In Anticipation of Sharing Pediatric Inpatient Notes: Focus Group Study With Stakeholders

Smith¹,

Kelly²

2022

J Particip Med

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Background Patient portals are a health information technology that allows patients and their proxies, such as caregivers and family members, to access designated portions of their electronic health record using mobile devices and web browsers. The Open Notes initiative in the United States, which became federal law in April 2021, has redrawn and expanded the boundaries of medical records. Only a few studies have focused on sharing notes with parents or caregivers of pediatric patients. Objective This study aimed to investigate the anticipated impact of increasing the flow of electronic health record information, specifically physicians’ daily inpatient progress notes, via a patient portal to parents during their child’s acute hospital stay—an understudied population and an understudied setting. Methods A total of 5 in-person focus groups were conducted with 34 stakeholders most likely impacted by sharing of physicians’ inpatient notes with parents of hospitalized children: hospital administrators, hospitalist physicians, interns and resident physicians, nurses, and the parents themselves. Results Distinct themes identified as benefits of pediatric inpatient Open Notes for parents emerged from all the 5 focus groups. These themes were communication, recapitulation and reinforcement, education, stress reduction, quality control, and improving family-provider relationships. Challenges identified included burden on provider, medical jargon, communication, sensitive content, and decreasing trust. Conclusions Providing patients and, in the case of pediatrics, caregivers with access to medical records via patient portals increases the flow of information and, in turn, their ability to participate in the discourse of their care. Parents in this study demonstrated not only that they act as monitors and guardians of their children’s health but also that they are observers of the clinical processes taking place in the hospital and at their child’s bedside. This includes the clinical documentation process, from the creation of notes to the reading and sharing of the notes. Parents acknowledge not only the importance of notes in the clinicians’ workflow but also their collaboration with providers as part of the health care team.

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Section: Discussionmentioning

confidence: 59%

Section: Discussionmentioning

confidence: 96%

Section: Discussionmentioning

confidence: 99%

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In Anticipation of Sharing Pediatric Inpatient Notes: Focus Group Study With Stakeholders

Smith¹,

Kelly²

2022

J Particip Med

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“…We chose to write a European White Paper as it is already complex to take into account the variations in ethical, legal, spiritual care, healthcare and cultural aspects that determine documenting within Europe. Within the European context, charting is increasingly a topic of research as the Swiss project has shown in 2018-2021(Peng-Keller & Neuhold, 2020.…”

Section: Why a White Paper?mentioning

confidence: 99%

“…Feed-back from patients is important. Even more patient participation and involvement is gained where shared or open notes have been used(Richards et al, 2021), that is, that patients get insight in what has been written. In a process of so-called "co-writing", the patients' notes could even become more important in the future of whole person care.…”

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confidence: 99%

Charting by Chaplains in Healthcare

Vandenhoeck¹,

Verhoef²,

Nuzum³

et al. 2022

HSCC

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“If it is not charted: it did not happen.” The charting of healthcare chaplaincy contacts in patient files has been controversially discussed in the literature in recent years. In particular, entries in digital medical records raise questions among pastoral care managers about confidentiality, data protection regulations and managerial interests. The European White Paper on charting in healtcare chaplaincy argues that charting chaplaincy contacts with patients and relatives (1) makes their spiritual needs visible, (2) contributes to improved interprofessional communication about chaplaincy and (3) makes the work of chaplains transparant. Charting improves the quality of care for patients, promotes the professionalism of chaplaincy and facilitates interdisciplinary exchange and multi-professional cooperation. It should be noted that entries in patient files should be made as if the patient were reading them. Descriptions must be adequate, understandable and concrete: The reason for the contact, assessment, changes resulting from the contact, interventions made and further planning are five steps of patient-centred pastoral care documentation. They respect patient rights and the principles of clinical ethics. In each case, questions of the software used, access rights and the use of the collected data material need to be clarified. The documentation of chaplaincy contacts can improve the relationship between patient and chaplain if it is included in the care. Last but not least, chaplaincy charting creates a data basis for practice-oriented research and training and for the development of the profession.

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