Open notes

[childay]

Letting certain psych patients having access to their charts is very problematic. You think I am delusional? Borderline? Now I am homicidal!

Likely surprisingly to non psychiatrists, almost every borderline PD patient I have ever had such a discussion with immediately attached to the diagnosis. I will give them the DSM criteria and everything (part of all of our reluctance is the negative connotation BPD has in medicine, non medical folks mostly have never heard of it).
Delusional patients yeah that's another story. Psychosomatic patients similarly problematic with open notes I suspect

[artemis]

At my new practice, we also have a habit of doing multiple addendums on certain cases (bone marrows come to mind). The slides may be negative, but molecular or flow come back positive.

This just sounds like a trainwreck waiting to happen...

And that's why I won't release a path report when diagnostic tests (as opposed to prognostic testing such as ER and PR status on a breast tumor) are still pending. People ACT on preliminary diagnoses (and most patients certainly won't understand why the initial diagnosis was changed). I'll chat with a clinician about the case over the phone, but I won't issue an actual report into the medical record (never mind a patient portal) until my diagnosis is final.

[StateOfMyHead]

Key point - don't be putting offensive stuff in your notes, and reasonable patients will be reasonable. Some may question the validity of the documentation and rightfully so in many cases the patient is right on calling it out.

I'm guessing you aren't a psychiatrist.

[SerrateAndDominate]

And that's why I won't release a path report when diagnostic tests (as opposed to prognostic testing such as ER and PR status on a breast tumor) are still pending. People ACT on preliminary diagnoses (and most patients certainly won't understand why the initial diagnosis was changed). I'll chat with a clinician about the case over the phone, but I won't issue an actual report into the medical record (never mind a patient portal) until my diagnosis is final.

Agree entirely. I have bucked the trend on this. The few times I've followed the old habits included issuing a broad category and mentioning case being sent out.

[StarTrekDoc]

I'm guessing you aren't a psychiatrist.

Primary care -- plenty of DSM level issues. Plenty people equally upset with morbid obesity and sleep apnea as major depression, etoh dependence, opioid dependence, or panic attack.

[artemis]

Agree entirely. I have bucked the trend on this. The few times I've followed the old habits included issuing a broad category and mentioning case being sent out.

Many years ago, we had someone find a back door into our pathology cytology module that allowed them to see the preliminary diagnosis made by the cytotech. We found out about this one day at Lung Tumor Board, where the clinicians stated talking about a patient whom I had diagnosed as having a carcinoid tumor, saying his path report showed he had small cell carcinoma. I said "Wait a minute, that's wrong!" and looked at the report they had, which lacked my electronic signature and as therefore not the final diagnosis (something they hadn't noticed). It turned out that based on that preliminary report, the patient had already been told he had lung cancer. That was fun (NOT)!

[SerrateAndDominate]

Many years ago, we had someone find a back door into our pathology cytology module that allowed them to see the preliminary diagnosis made by the cytotech. We found out about this one day at Lung Tumor Board, where the clinicians stated talking about a patient whom I had diagnosed as having a carcinoid tumor, saying his path report showed he had small cell carcinoma. I said "Wait a minute, that's wrong!" and looked at the report they had, which lacked my electronic signature and as therefore not the final diagnosis (something they hadn't noticed). It turned out that based on that preliminary report, the patient had already been told he had lung cancer. That was fun (NOT)!

Yeah that's alarming. I had a similar situation at fellowship last year when doing my clinical time. One of the derms was asking me about a case and showed me how she was able to read prelim (not even officially prelim'd in Epic). I had a chat with my bosses, and there were some rapid fixes to Epic that week

[gap55u]

The studies on open notes apparently say that patients are more involved in their care and understand better. I’m not sold on that, but it helps with adult children following dad’s care by portal, to be honest. I know my peeps with an OCD streak and document a little differently for them lest I get stupid chart correction requests. I did have one clinically significant request (someone else had an in-fact incorrect diagnosis in PMH). I also have tried to make my a/p section a little more layman without it taking mental effort on my part.

[endo4jc]

I don’t think having immediate, transparent access is helpful for patients at all. Maybe having access to the plan of care? Otherwise just seeing the myriad high and low lab values has the potential to draw questions. My brother recently asked me about his high and low values from his physical (doc... why is my mean corpuscular volume low???!!!!!).

Some of y’all may be familiar with MediTech and it’s charting woes. One good thing is that, at least to my knowledge, I cannot use a pre-filled template for PE so I am actually quite short with my exam and only document for other systems what can be observed (non-labored respirations for pulm). I mean, I could put my ear to the orthopaedic auscultation point and hit three systems at once.

[Lordosis]

I don’t think having immediate, transparent access is helpful for patients at all. Maybe having access to the plan of care? Otherwise just seeing the myriad high and low lab values has the potential to draw questions. My brother recently asked me about his high and low values from his physical (doc... why is my mean corpuscular volume low???!!!!!).

Some of y’all may be familiar with MediTech and it’s charting woes. One good thing is that, at least to my knowledge, I cannot use a pre-filled template for PE so I am actually quite short with my exam and only document for other systems what can be observed (non-labored respirations for pulm). I mean, I could put my ear to the orthopaedic auscultation point and hit three systems at once.

I have not heard this before and it gave me a good laugh. Thanks.

[hightower]

One of my old hand surgery partners had ridiculous stuff in his notes—things like “no rubs, murmurs, or gallops,” and “no hepatosplenomegaly.” A complete joke.

Our hospital also started an orthopedic urgent care and the outrageous stuff the primary care sports med docs document in their notes is beyond ridiculous. It’s complete fraud. I saw one young female referred from there for wrist pain and the doc had put things on there about her not having scoliosis and normal deep tendon reflexes, amongst other ridiculous things (complete abdominal and heart exam). I asked her if they had examined her back, or tested reflexes, or touched her belly or listened to her heart, and of course they hadn’t. I brought it up to the head of our department and he basically told me to keep my mouth shut because they made a lot of money. I’ve lost more respect for doctors by reading their notes than just about any other way.

The reason notes have become filled with overly extensive PE and ROS is 100% because of the rules surrounding billing and documentation. If you don’t document extensive, detailed exams and ROS you can’t legally bill for more than a level 1 encounter which would mean going out of business for most practices. I cant blame people for trying to pad their notes. I do try to avoid documenting things I don’t routinely do though such as cranial nerve exams etc. Maybe I’ll be a bit more careful with this new rule BUT if you think about it, lawyers have always had open note access when a patient files a lawsuit, so this really shouldn’t change anything about our documentation. We should write every note with the assumption that a lawyer might be reading it someday.
One of the biggest reasons I dislike this career.

[MoneyMoth]

Our EMR specifically has a section for notes that will not show up on the actual physically printed or faxed chart records.

I know some of my colleagues are still wary of that feature and instead prefer to use coded language in their notes. Never caught on with me, I didn't want to have to explain why all the patients that give me bad reviews online also have the word "magenta" conveniently squeezed into their notes.

Reminded me a little of: https://www.youtube.com/watch?v=qkM-tTkUbOw

[Lordosis]

I have always wanted a section that is only available to me. This way I can write the stupid things that help me remember the important details.

Pain in the a$$
Always pushes for ABX
Always is late
Malpractice attorney

[jacoavlu]

I have always wanted a section that is only available to me. This way I can write the stupid things that help me remember the important details.

Pain in the a$$
Always pushes for ABX
Always is late
Malpractice attorney

I’m a radiologist. I’ve always assumed when I read clinical notes that the over exuberant “this super lovely pleasant young man” type language was the code for pain in the ******************

[MoneyMoth]

I have always wanted a section that is only available to me. This way I can write the stupid things that help me remember the important details.

Pain in the a$$
Always pushes for ABX
Always is late
Malpractice attorney

The nice thing about having a horribly inefficient system is that you can hide notes in your practice management software (which at our hospital, is separate from our EMR, barely communicates with our EMR, and by requiring that we keep two windows open at any time, you are always on the verge of being timed out from the system you actually want to use)

So some of my colleagues will keep their EMR notes pristine and can hide all sorts of interesting tidbits in the practice management / scheduling software program

Now that I re-read my posts, it sounds like all we see are highly troubled patients...