Open Progress Notes and Discharge summary; What hospitalists need to know.

The 21st Century [Office of the National Coordinator for Health Information Technology] ONC’s Cures Act Final Rule includes a provision requiring that patients can electronically access all of their electronic health information (EHI), structured and/or unstructured, at no cost.

In 1996, the Health Insurance Portability and Accountability Act (HIPAA) allowed patients access to the information in the medical records.

Most people in the US are now already able to use patient portals to view test results, make appointments, request medication refills, and also message their doctor.

Lot of hospitals, however, do not have Open Notes policy yet.

Pros of Open Notes Policy:

Open notes policy for hospital progress notes and discharge summaries can increase opportunities for shared decision-making, improved patient engagement, and patients’ ownership of their health.

The chance of missing on an abnormal incidental finding comes down as patient will be aware of abnormal imaging or lab results.

“Open Notes” policy may improve patients’ trust on hospitals and healthcare professionals and may also increase patient satisfaction.

Patients may better understand their doctors’ reasoning behind their treatment recommendations and may increase their compliance with treatments.

“Open Notes” policy may save time for hospitalists as the patient and patient’s family already know the plan for the day and they might just ask one or two questions if they have doubts after reading your plan.

However, there are certain things the patients may have issues with.

Cons of Open Notes Policy:

A patient with no medical knowledge now suddenly starts reading medical terminology which is difficult for an average person to understand.

Patients may not like some of their diagnoses documented in the chart even though they are accurate and might want them removed which makes clinical documentation incomplete.

It’s very important that the hospitalists make some changes to the clinical note making to make the process smoother.

What can Hospitalists do?

Here are some ways, hospitalists can start making some changes to the documentation to minimize confusion to the patients and to minimize spending time to explain to the patients what the documentation actually means.

Avoid abbreviations/acronyms in the progress notes and discharge summary. The patients may understand wrongly and will ask you when you see them again or may even want the nurse to call you to talk to them as soon as possible. POA=Present on admission, HCC=Hierarchical Condition Category. It may be better to spell out abbreviations like HEENT, PERRLA, CVS, CNS, CVS used in physical exam. Some others like DVT, HOB, GI used in assessment and plan can be spelled out. Just change the template one time and all these can be taken care of.

Make sure to do the physical examination that you document. Do not document any physical exam that the doctor did not do.

Make your notes short and sweet to avoid raising unnecessary doubts to the patient which in turn will waste your time explaining next time you meet the patient.

Do not avoid writing Morbid Obesity as a diagnosis when the BMI is high. It’s an ICD 10 code and can’t be coded if not documented. It is a one of the major risk adjustment factors to which reimbursement is tied. Same way, make sure to document substance abuse/dependence or withdrawal when relevant.

Avoid using terms like ‘complains’, ‘refused’, ‘drug addict’, ‘drug seeker’ etc as much as possible. Instead use terms like ‘reports’, ‘declined’, ‘injection drug usage’, ‘concern for drug seeking behavior’ may be little softer words to use. At the same time, documentation should be accurate, objective, and nonjudgmental. 

It is very important to make sure Admission Medication Reconciliation is done and document if any changes to home meds were done as family of the patients may be concerned when medications are stopped.

Doctors may have to stop using phrases like “patient appears older than her stated age”.

In situations where there is disagreement between the doctor and the patient, use “we agree to disagree on…” while documenting.

Whenever possible, use patients’ own words in quotes about sensitive information to avoid any issues. Basically avoid any words that one would not say in front of a patient. Try to highlight patient strengths along with documenting vulnerabilities or weaknesses.

Use actual dates like “EGD [EsophagoGastroDuodenoscopy] is planned for 10/8/2020” instead of “EGD is planned for tomorrow.” This way when one copies and pastes, errors will be minimized.

However careful a doctor writes a progress notes, there will be times the patient wants notes to be corrected. Expect this and deal with it calmly.

I would think that it is better to write notes earlier in the day as you can answer any questions from the patient or their family member. Or else, late documentation may result in the questions from the patient or family member later in the day and can make you more busier towards the end of the day.

It is important to make sure that patient receives Notice of privacy practices (NPP) which includes the information about open notes. It is better for the hospitalist to discuss about the availability of progress notes and discharge summary in patient portal and ask the patient if they do not want all or any portion of the notes to be available in the portal.

It is a good idea for the hospitalists to make the patient and the care giver of the patient aware of the presence of any sensitive information like genetic test results or psychiatric history in the notes and make sure they are ok with that. If not, that information should not be released.

This is a good time to go back to the templates for progress notes and change where needed to minimize errors or inconsistencies if any.

Make sure to remove the signature and date stamped at the bottom of the note from previous day. It is easy to forget this and the progress notes may have two different or even worse, more than three date stamps from previous days. This happens in EPIC all the time.

The above are not legal advices and every hospitalist should be aware of their own hospital’s policies for using this open notes policy safely.

Conclusion:

There were a lot of changes in healthcare in the country in the past few years. Hospitalists were one of the key players in this ever changing healthcare environment. Hospitalists have survived all the changes so far and will adopt quickly to this new change too.

References: 1 2 3

2 thoughts on “Open Progress Notes and Discharge summary; What hospitalists need to know.”

    • I agree. We have to make them easier to understand by patients from now onwards due to open notes policy. That could really help patients better understand their health issues and take better care for themselves.

      Reply

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