As more patients access their EHRs, should physicians change how they make notes?

More often, patients are accessing their own medical records, usually based on encouragement from physicians who want to better engage them in their own care. But what happens when they come across terms or jargon they don't understand, or worse, words and phrasings regularly used by physicians that patients find offensive?

Words like "obese" or "depression" may mean one thing among physicians, but when read by patients as descriptors in their own EHRs, can be misconstrued to feel condescending or judgmental, Jeremy Olson wrote in a report for the Star Tribune.

Physicians are well aware that acronyms, shorthand and certain words that are second nature to them may be not at all right for communicating actionable or even accurate information to patients. But implementing a standardized change in how clinicians annotate in medical records could be time consuming and difficult, Pamela Doorenbos, MD, a Maple Grove, Minn.-based physician told the Star Tribune.

Others are more confident that through programs such as OpenNotes, a nationwide initiative aimed at getting more patients to access their EHRs, people will become more educated about their care even if they have to do a bit of research while they read through their physicians' writing.

Should the practice of sharing notes with patients become even more widespread, some of the stigma about words with confrontational or offensive connotations might be lifted, and patients may by default better understand and become more accepting of how and why physicians speak and write the way they do.

If nothing else, sharing the records will help patients stay refreshed on instructions and recommendations from their providers, regardless of whether they understand or agree with every word, Mr. Olson wrote.

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