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The Open Notes Project | Read the Doctor's Notes



How comfortable are you about sharing your notes with the patient?

We’ve all seen our doctors scribbling in our charts after the exam. Now new research is exploring whether it’s a good idea to let a patient read the doctor’s notes, reports the Informed Patient column in today’s Wall Street Journal.

A study currently under way, called the OpenNotes project, is looking at what happens when doctors’ notes become available for a patient to read, usually on electronic medical records. In a report on the early stages of the study, published Tuesday in the Annals of Internal Medicine, researchers say that inviting patients to review the records can improve patient understanding of their health and get them to stick to their treatment regimens more closely.

But researchers also point to possible downsides: Patients may panic if their doctor speculates in writing about cancer or heart disease, leading to a flood of follow-up calls and e-mails. And doctors say they worry that some medical terms can be taken the wrong way by patients. For instance, the phrase “the patient appears SOB” refers to shortness of breath, not a derogatory designation. And OD is short for oculus dexter, or right eye, not for overdose.

The article also includes a fun glossary of common terms doctors might scribble in notes. Among others, there’s “NERD” for “no evidence of recurrent disease,” and “Shotty,” which is shorthand for “mildly enlarged lymph nodes.”

Are there differences if you are a homeopath, heart surgeon, psychiatrist, general practitioner?

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Comment by Debby Bruck on July 23, 2010 at 12:27am
There is a much more lengthy article at the link above. The patient can misinterpret many of the scribbles and notes. But, this also requires more open communication between physician and patient.

I have always been taught to be very open and honest with clients. And to make sure that I restate their words precisely to make sure that I understand their meaning. I, personally, do not make any diagnosis and they usually come in to the office with that information and clinical notes.
Comment by Debby Bruck on July 23, 2010 at 12:25am
Absolutely true, Dr Rafeeque. Do we use the rubric "shock, fear, or panic from bad news?"
Comment by Dr Muhammed Rafeeque on July 23, 2010 at 12:12am
The recent studies conducted at Mc Master university on the disease diagnosis is remarkable. They found that the name of the disease creates more panic among the patients. For example, a person having sour eructation may not feel bad when the doctor says that he has acidity, on the other hand, he may get embarrassed if the doctor tells him that he has Gastro-esophageal reflex disease, which is the medical terminology for recurrent burning eructations. The same thing happens in most of the cancer patients; once the disease is diagnosed as cancer, the patients mental and emotional status starts deteriorating. But, the doctor cant hide the disease from the patient due to several medical and legal issues. The better alternative is to secretly tell the diagnosis to the bystanders of the patient.

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