8 ways to write notes your patients will actually read

The progress note used to be a document physicians wrote for other physicians, for coders and for auditors. That changed when the federal information blocking rules took effect, requiring practices to release clinical notes through the portal without delay. The note now reaches the patient before the parking validation expires.

Patients are reading, and they are catching things. In a survey of nearly 30,000 patients published in JAMA Network Open, one in five patients who read a visit note reported finding a mistake, and about 40 percent of those patients considered the mistake serious. Errors in diagnoses, medical history and medication lists led the list. A growing share of patients are also pasting notes into a chatbot to have the language translated, which means a sloppy sentence no longer just confuses one reader. It gets amplified and interpreted.

The reflex is to write more defensively. That is the wrong lesson. OpenNotes research has found that patients who read their notes report better recall of the care plan and better medication adherence, while only about 3 percent report confusion, a small fraction of what clinicians predict. Documentation is a patient communication channel physicians are already paying for with their evenings. Here are eight ways to make it earn that time.