ISBN-13: 9783031436321 / Miękka / 2024 / 320 str.
The Patient-Centered Approach to Medical Note-Writing
1. Introduction: Why this book?
2. A History of Medical Charts: Who owns it and who is it for?
3. Patient-Centered Language: General Principlesa. Language evolves
b. Bias going in: positive and negative
c. Bias going out: impact upon readers
d. Race and ethnicity
e. Gender
f. Body habitus
g. Reconsidering what is “normal”
h. Jargon: sometimes useful, sometimes noti. Quotations and attributions
j. Auto-populated templates
k. Diseases and labels
l. Rules and Regulations (United States): The Cures Act
4. The Chief “Complaint” and History of Present Illness
a. Chief Complaint (“the one-liner”)
i. Age
ii. Gender
iii. Race/Ethnicity
iv. Included medical conditions
v. Included social history
vi. Language proficiency and use of interpreters
b. History of Present Illness
i. Refusals, deferrals, and noncompliance ii. Positive language iii. Negative language iv. Stereotyping v. Denials and endorsements 5. The Problem List / Medical Historya. “Problem” List: is it a problem?
b. Past vs Current Medical History
c. FYIs and Warnings
d. Potentially sensitive topics
6. The Social History, Substance Use, and Lifestyle Habits
a. Living situation
b. Occupation
c. Substance use
d. Lifestyle habits (e.g. exercise)
e. Race/Ethnicity
f. Safetyg. Incarceration
7. The Review of Systems and the Physical Examination
a. Review of Systems
i. Denials and Endorsements
b. The Physical Examination:
i. General appearance descriptors: pleasantness; cleanliness, neatness, smell
ii. Age: What is middle-aged?
iii. Race and ethnicity
iv. Weight, body mass index, and body habitus
8. The Assessment and Plan
a. Summary one-liners
b. No surprises: Consistency with verbal communication
c. Positive and negative language (similar to HPI)
d. Negotiation documentation: collaboration
9. Patient emails and phone calls
10. Difficult encounters
11. Oral presentations
Christopher Wong, MD is an Associate Professor of General Internal Medicine at the University of Washington. He is a clinician-educator in primary care, practicing medicine at the university outpatient clinic as well as teaching medical students and internal medicine residents. His academic career has focused on general medical topics, including perioperative medicine, preventive health and primary care training. He is the editor of two books with Springer: co-editor of the first edition of The Perioperative Medicine Consult Handbook (2013) and sole editor of Primary Care of the Solid Organ Transplant Recipient (2020).
Dr. Wong has been teaching students and residents on the subject of patient-centered medical notes for many years. The University of Washington was one of the early sites for the “Open Notes” project in which patients have routine access to their medical records—providers there have many years of experience working and teaching in this clinical setting.
Sara Jackson, MD, MPH, is an Associate Professor of General Internal Medicine at the University of Washington. She practices primary care in an academic outpatient clinic at Harborview Medical Center, which serves the safety-net population of King County, WA. In addition to patient care, she teaches internal medicine residents in clinic, and serves in an administrative role as Associate Medical Director for Ambulatory Clinics at Harborview. Her scholarly work in the area of health services research has focused upon women's health and equitable health care delivery. She was also involved in the original Open Notes study at UW in 2010 and has been writing and teaching about experiences with Open Notes since then.
Medical chart notes have moved from the cloistered purview of clinicians into the age of transparency. The availability of electronic medical records and the enactment of federal regulations in the United States have combined to make documentation more easily accessible to patients. The writing of clinical notes, however, has not kept pace with modern expectations. Chart notes have traditionally been thought to serve the purpose of good medical communication, itself a task not always performed with success. Now, however, the ability of patients to read their own notes has brought to light the often-ignored responsibilities of also conveying humanity, withholding judgment, and being patient-centered. Many charting practices common in clinical medicine are now outdated as clinicians have reconsidered how to write notes that patients will be reading.
Virtually every part of the medical record is affected by the language used by the writer, from the very first line of a medical history to the complexities of patient preferences for testing and treatment. For example, it was once commonplace to identify a patient in racial or ethnic terms (e.g. “50 year old African-American man presents with…”), or as their disease (e.g. “60 year old diabetic”) or behavior (e.g. “25 year old injection drug user”) rather than as a person. Other writing practices are more subtle, including the use of stigmatizing language in the narrative (history of present illness) or the physical examination. In some cases, the stigmatizing language may reflect an internal bias on the part of the writer, while in others it may simply be unknowing connotations brought forth from a lay reader.
The clinical impact is twofold: One, charting that is not patient-centered can erode patient trust, as studies have shown that patients find certain types of language judgmental or offensive. Two, there is evidence that stigmatizing language can bias the next person who reads the chart note, thereby potentially affecting future treatment of the patient. These impacts are compounded by electronic records in which problematic language exists in perpetuity.
There is a need for a comprehensive reference on how to write medical notes in this new era. There is no current text that fills this gap. The Patient-Centered Approach to Medical Note-Writing is a vital reference for students, residents and fellows as well as medical educators while also appealing to practicing clinicians who use an electronic medical record in which patients read notes written about them.
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