Affiliation:
1. Boston Children’s Hospital and Harvard Medical School, USA
2. Prisma Health and University of South Carolina School of Medicine Greenville, USA
3. University of Alabama at Birmingham, USA
4. Western Michigan University Homer Stryker M.D. School of Medicine, USA
Abstract
Abstract
Objectives
The 21st Century Cures Act included an “OpenNotes” mandate to foster transparent communication among patients, families, and clinicians by offering rapid electronic access to clinical notes. This article seeks to address concerns about increased documentation burden, vulnerability to patient complaints, and other unforeseen consequences of patients having near-real-time access to their records.
Methods
This topical review explores both extant literature, and case examples from the authors’ direct experience, about potential responses/reactions to OpenNotes.
Results
The ethics of disclosing medical information calls for nuanced approaches: Although too little access can undermine a patient’s autonomy and the capacity for truly egalitarian shared decision-making, unfettered access to all medical information has significant potential to harm them. Suggested strategies for mitigating risks in premature disclosure include patient and provider education and “modularizing” sensitive information in notes.
Conclusion
The OpenNotes era has ushered in the possibilities of greater patient and family collaboration in shared decision-making and reduced barriers to documentation sharing. However, it has raised new ethical and clinician documentation considerations. In addition to clinician education, patients and families could benefit from education around the purpose of clinical documentation, how to utilize OpenNotes, and the benefits of engaging in dialogue regarding the content and tone of documentation.
Publisher
Oxford University Press (OUP)
Subject
Developmental and Educational Psychology,Pediatrics, Perinatology, and Child Health
Cited by
2 articles.
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