{"id":14952,"date":"2013-07-01T11:00:02","date_gmt":"2013-07-01T15:00:02","guid":{"rendered":"http:\/\/pmedicine.org\/epatients\/?p=14952"},"modified":"2013-07-01T11:00:02","modified_gmt":"2013-07-01T15:00:02","slug":"on-the-road-to-shared-of%ef%ac%81ce-visits","status":"publish","type":"post","link":"https:\/\/participatorymedicine.org\/epatients\/2013\/07\/on-the-road-to-shared-of%ef%ac%81ce-visits.html","title":{"rendered":"On the road to shared of\ufb01ce visits"},"content":{"rendered":"

Guest blogger Peter Elias, MD\u00a0 describes his journey\u00a0on opening up his office notes to patients.\u00a0Peter is a family physician in active primary care practice since 1977, co-founder of a group practice now owned by a hospital-based multi specialty group, with a dedication to patient centric care and interests in behavior and learning, information science, systems and the big picture, and with love of his family, nordic skiing, hiking and thinking for himself. The author\u2019s blog is<\/em>\u00a0PeterEliasMD (personal observations and perspectives<\/a>.<\/p>\n

Nearly a year ago I embarked on an adventure that has been changing how I practice medicine. It is also changing how medicine feels.<\/p>\n

It began quite innocently. During an office visit to discuss a new diagnosis of a serious and chronic illness, we talked about problems inherent in the need to involve several physicians practicing in three different communities, I explained that because there is no unified patient record and clinical systems do not share information. the patient and his wife would have to help manage this. They should request a copy of all his evaluations, tests and treatments, keep these organized in a notebook or other file, and bring their information to visits. As they were leaving, they asked how to get a copy of the note from today\u2019s visit. (My institution does not provide a secure portal for patient access or communication.) I told them that I finished my day\u2019s notes every evening and would send them a copy the next morning. Reviewing his note that evening, I had an epiphany: my notes were written from my perspective and designed to help me. My intent was a real-time transcription of the interaction, but only from my personal perspective. The notes described my agenda, my assessment of the patient\u2019s condition, my understanding of the plan, and my recommendations. They sometimes included comments that were accurate but inappropriately phrased and troublesome: \u201cHistory challenging because patient\u00a0disorganized.\u201d \u201cPatient has DM but has not had surveillance lab done for 12 months.\u201d \u201cSeen here by X two weeks ago but no note in chart.\u201d They were detailed, accurate and organized, but could have been written without the patient being involved. In fact, they WERE written without the patient being\u00a0involved.<\/p>\n

It was easy that evening to edit the \u2018Plan\u2019 part of his note, listing the items we had agreed upon as our plan going forward, but the discordance between what had been a very collaborative interaction and my physician-centric note was painful. During the next few weeks, the experience haunted me. I found myself wondering as I did my notes, \u201cWhat would the patient think if he\/she read this?\u201d\u00a0I now think of that as Stage 1: realization. I needed to make the assessment and plan reflect the collaborative process and our shared understanding of the visit.<\/p>\n

My approach to writing notes began to change, and MY assessments began to look like OUR assessments. I began to more frequently use the \u2018Patient Instructions\u2019 page to list and then print our shared plan. This was Stage 2: limited and marginal change. It was still my note, but I began increasingly often to record the assessment in patient-friendly language and provide a record of my understanding of the plan.<\/p>\n

I began printing and providing occasional office visit notes to selected patients, but it was a struggle and made me uncomfortable.<\/p>\n