If you spend time nosing around medical charts you’ll find that the quality of physician notes vary as much as the doctors who creates them. Even as physicians we sometimes have difficulty understanding what’s happening or where a patient is headed in their care.

An informed patient begins with clean information

It got me thinking of OpenNotes. This is a tremendous initiative started at Boston’s Beth Israel Deaconess Medical Center that facilitates patient access to traditionally restricted medical notes. Access seems like the perfect starting point for an informed, empowered patient. But If a doctor can’t make sense of a note, how can a patient?

The hang-up isn’t an issue of medical jargon or technical stuff. It’s the basic organization of information gathered during a visit and the thinking that goes into an impression and plan. A patient or allied professional reading our notes should have some sense of what we were thinking at the time of an encounter.

Clear physician notes are not an EHR problem

And this isn’t an EHR problem. Doctors alone take the history, compose the impression, and shape the plan. It’s the part of the EHR that’s all us. There are a million excuses why doctors can’t pen a simple impression that shows their thinking. We need to be accountable for what we create on behalf of our patients.

To be clear this is a struggle for me as much as anyone else. It’s easier to be vague and quick than clear and complete. Translation and composition of our thoughts takes presence of mind (mindfulness, for a variety of reasons, is one of the greatest challenges for the contemporary physician – maybe this is where we break down).

Physician notes as story

Perhaps we should start the Clean Note Project. This would strive for clean and clear communication in the human-controlled spaces of the EHR – that’s the part we write. This would make patient access to the record more valuable. It would make the sharing of ideas within the chart invaluable.

Victoria Sweet in her new book, Slow Medicine suggests,

The essence of Medicine is story—finding the right story. Healthcare, on the other hand, deconstructs story into thousands of tiny pieces for which no one is responsible.

A patient’s access to physician notes is only as good as the notes themselves. And that’s where a good story and great care should start.

Image modified via Colin Chazaud on Flickr