Respectful Patient Care Starts With Your Clinic Notes

As a follow-up to these articles, it is important to discuss how we write our clinic notes. Our previous articles focused on how we talk to the patient in real time during the office visit. This same respectful language needs to be conveyed in our clinic note documentation as well. As we document, we need to remember to write with respect. A recent emergency room note that I read about one of my patients reminded me of this. The note referred to my patient as a person who is experiencing housing insecurity, a much more respectful reference than a past note that had labeled him as “homeless.” I imagined reading such a note about myself and wondered how I would feel.

We APPs always need to be aware as we document our clinic visits to think about how they may sound if the patient is reading the notes. Are we as clinicians writing our notes with respect and understanding for not only other providers who may read this note but also for the patients themselves?

The 21st Century Cures Act made health care more transparent to patients as well as the care team. Research has found that there are significant benefits to patients who have access to their electronic health records, including having increased confidence, feeling more in control, and having a greater opportunity to review potentially confusing information from office visits.¹ When we write our clinic notes, we may not always be thinking about who may be reading the notes. But I know that many of my patients are reading their clinic visit notes, with some of them even reaching out to me to correct a misspelling or to remind me of something that was said that I failed to document in the visit.

In addition to respectful communication, another thing to consider is the stigma that we as clinicians may project onto patients, often unknowingly. It is important to read previous notes that indicate patient pronouns. If it is not clear in prior documentation, ask the patient during that first visit and be sure to clearly document their pronouns in the clinic visit notes. More importantly, continue to consistently use appropriate and sensitive language in documentation.²

There can also be stigma associated with drug abuse. How we document this is important, and we must remain judgement-free. Instead of referring to a patient in the note as a “noncompliant addict,” consider writing, “the patient is having difficulty coming for cancer treatment while dealing with opioid addiction.”² Another opportunity for stigma-free documentation is associated with opioid use disorder and how we talk about managing pain. A good way to express this in documentation would be to state that opioid use disorder can make pain management challenging and avoid using terminology that would indicate blame.

As a rule, I often re-read my notes before signing them. Read your clinic visit notes as if you are the patient and ask how they would this sound. Is it offensive? Does it appear to assign blame? Does the note preserve the dignity of the patient? Have you ever been upset with someone and you wrote a note or email and asked someone else to read it first before you send it so that you don’t sound too accusatory? While you cannot ask others to read your patient notes before signing them, always be cognizant of the words and tone of your notes, because at any time, the patient may be reading it.