​MSHR Open Clinical Documents

Patient-centred writing tips for providers

Overview

When it comes to open clinical documents, think one document – many uses. Some key things to keep in mind include:

  • Clinical documents are designed as a tool between care providers.
  • Patients can already access all of the information in their charts upon request. Including clinical documents in MySaskHealthRecord (MSHR) will make it easier for patients to access their information.
  • Patients can play a huge role in their own care. Providing access to clinical documents in MSHR will increase patient engagement and empowerment. It can improve trust in providers and strengthen patient-provider relationships.
  • The majority of patients will be able to get the information they need on their own from clinical documents. Some will need help understanding the information.
  • Authors using SCM, Fluency for Transcription/Fluency Mobile or Fluency Flex will be able to exclude clinical documents from MSHR in accordance with HIPA critera. Self-directed training will be available in MyConnection to show users how to exclude documents in the eHR Viewer from MSHR in accordance with HIPA criteria.
  • Clinical documents finalized prior to rollout will not be added to MSHR
  • You may already be doing many of the things suggested below, such as sharing copies of clinical documents/reports with patients.
Tips for Providers
These tips are based on what providers in other jurisdictions have experienced when sharing clinical documents with patients and how their dictation/writing has evolved. You may find these tips helpful to consider.

Be clear and concise
  • Try to use direct and simple language when possible, remembering that the patient will read the note.
  • Avoid jargon or abbreviations when possible.
Be direct and respectful – consider word choices and tone
  • Discuss what you dictate/write and dictate/write what you discuss. Include topics you've discussed with your patient to help reinforce their memory of their care plan.
  • Address sensitive issues directly. Examples include obesity, malignancy and substance use. Be clear and remember that patients are likely concerned about these.
    • Obesity: review BMI and definitions for overweight, obese and morbidly obese and focus on positive changes the patient has made with diet, exercise and weight loss.
    • Malignancy: outline specific symptoms concerning for cancer and note referral or tests for prompt diagnosis.
    • Substance use: explain the connection between substance use and the patient’s condition.
Be positive and supportive
  • Use direct but caring words. Be objective. This can help to overcome denial, destigmatize and even motivate behavior change. Dictate as though the patient is with you, hearing you.
  • Focus on patient’s strengths and achievements. Consider using notes to motivate patients and give positive feedback. Consider placebo effect (e.g., "He's done a great job").
  • Be objective but not judgmental (e.g., use "declined" rather than "refused" or "patient chooses not to" rather than "patient is noncompliant").
  • Eliminate any language that might be critical of the patient or another provider.
  • Be respectful and supportive of other healthcare providers. Include information constructively to assist other providers in delivering the best standard of care.
Include patients in the note-writing process
  • Think of clinical notes as a communication tool.
  • Explain to your patient that they can read their notes in MSHR and encourage them to do so.
  • Check with patients during their visit to be sure they will understand the content that will be provided in the note.
Follow-up and use clinical notes to engage patients
    • Complete notes after the visit in a timely manner.
    • Draw attention to follow-up or future actions.
    • Consider using notes for patient feedback and follow-up.
Additional reading information

1.       OpenNotes. https://www.opennotes.org/

2.       The Canadian Medical Protective Association (2020, March). Writing with care. https://www.cmpa-acpm.ca/en/advice- publications/browse-articles/2020/writing-with-care

3.       Wolff, J. L. et al. (2016, August 7). Inviting patients and care partners to read doctors' notes: OpenNotes and shared access to electronic medical records. JAMIA, 24(e1): e166-e172. https://doi.org/10.1093/jamia/ocw108

4.       Hägglund, M et al. (2022, September 29). Patient empowerment through online access to health records. BMJ, 378:e0171531. https://doi.org/10.1136/bmj-2022-071531

5.       Blease, C. et al. (2020, November 27). Does patient access to clinical notes change documentation? Frontiers in Public Health, 8(577896). https://doi.org/10.3389/fpubh.2020.577896

6.       Leveille, S. G. et al. Patients evaluate visit notes written by their clinicians: a mixed methods investigation. J GEN INTERN MED 35, 3510-3516. https://doi.org/10.1007/s11606-020-06014-7

7.       DesRoches C. M. et al. (2020, March 27) The views and experiences of clinicians sharing medical record notes with patients. JAMA Network Open, 3(3): e201753 10.1001/jamanetworkopen.2020.1753

8.       Klein, J. W. et al. (2016, June 8). Your patient is now reading your note: opportunities, problems and prospects. The American Journal of Medicine, 129(10): 1018-1021. https://doi.org/10.1016/j.amjmed.2016.05.015 .

9.       Parikh, R. B. et al. (2022, May 31). Digital health applications in oncology: an opportunity to seize. Journal of the National Cancer Institute, 114(10): 1338-1339. https://doi.org/10.1093/jnci/djac108