Benefits and Risks Involved in Sharing Notes with Patients

Benefits and Risks Involved in Sharing Notes with Patients

Physicians are finding that the practice of providing patients with access to their medical records offers many benefits, but is not without risks.

www.medicaltranscriptionservicecompany.com

MTS Transcription Services United States

(800) 670 2809

Medical transcription companies take great effort to provide physicians with timely and accurate EHR-integrated documentation. This allows physicians to track patient progress and develop appropriate therapeutic interventions. Good medical record documentation promotes patient safety and defends physicians against allegations of malpractice. The practice of sharing progress notes with patients began with new payment considerations calling for improved patient engagement. HIPAA mandates that if a patient submits a written request for the medical record, the healthcare entity has to provide the information.

CMS criteria for meaningful use stage 2 also support patient access to physician notes.

Today, this transparency movement which began 2010 provides access to notes for more than 12 million patients nationwide. However, while the open notes strategy offers many benefits, many physicians are talking about its risks.

Benefits of Open Notes First, the benefits, as noted by various studies: •

Improves patient understanding of their health and medical care plan

•

Could improve patients’ control of their care

•

Enhances physician-patient communication

•

Promotes treatment adherence

•

Enhances transparency

•

Malpractice litigation risk could decrease for physicians who use open notes, since the practice will allow more open dialogue with the patient

•

Upon review of their record, patients may be able to offer some corrections

•

When patients ask for clarifications, it would lead to a more accurate diagnosis, and save time

•

Increases patients’ trust

In a study published in the American Journal of Medical Quality, the author points out that sharing notes increases the alignment of prognosis between the family and the medical team. When families read the physicians’ notes where the issues with poor-prognosis multiorgan failure are stressed, this might help families more quickly understand the futility of continuing care.

www.medicaltranscriptionservicecompany.com

(800) 670 2809

Pitfalls of Open Notes Seven years after it came into effect, physicians say that policy of note sharing with patients has its share of problems. At the recently held conference of the American College of Physicians (ACP) in San Diego, open notes was one of the key topics of discussion.

Physicians noted the issues involved as: •

Burdens practices with additional administrative work

•

Increases documentation time

•

Could lead physicians to “craft notes that are less than honest out of fear of offending or angering patients”, especially with regard to issues like weight, substance abuse or mental health

•

There is the risk of breach of confidentiality of health information if the access is not secure and patients are not aware about the importance of protecting their personal health data

The new patient engagement playbook of the Department of Health and Human Services (HSS) provides healthcare entities with instructions on providing patients and their proxies secure access to health information via patient web portals. Providers need to find out who is involved in the patient’s care, know the patient’s preferences for giving caregivers access to their health information, and work with the EHR vendor to ensure that the system has a secure login to the patient's portal.

When it comes to documenting large volumes of dictated progress notes, chart notes and other clinical material, busy physicians can benefit by outsourcing medical transcription to an experienced medical transcription company. Chart notes can be dictated in various formats such as a mini history and physical (H&P), a single paragraph with a few sentences, or using the SOAP (Subjective, Objective, Assessment and Plan) format or a close variation.

Moreover, there are specialty-specific SOAP note templates. Regardless of the requirement, a reliable medical transcription service provider can ensure well-organized, neatlymaintained patient charts and progress notes that can be easily read by provider and patient.

www.medicaltranscriptionservicecompany.com

(800) 670 2809