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Reduce Patient Concerns

Data: Documentation Matters

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Opening Your Notes: Patient Care Recommendations


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The OpenNotes website offers a wide range of tips and educational materials, including many of the following suggestions for note writing:

  • Continue using specific language that is required for billing and coding purposes.
  • Avoid copying and pasting that does not reflect the current encounter or patient status.
  • Don’t import social history if you did not elicit it or review with the patient.
  • Avoid abbreviations. Briefly define medical terms when feasible.
  • Be mindful of sensitive topics and avoid language that seems judgmental. Use language that describes your observations of behavior.
  • Include educational materials or links to trusted content for patients in your notes.
  • Incorporate lab or study results into your notes to give the full picture.
  • Use plain language whenever possible.
  • Use the patient’s preferred pronoun.
  • Use supportive language.


Specific suggestions include:

  • Document the patients BMI – not morbid obesity.
  • Document diabetes as a condition – not as an adjective.
  • Instead of describing non-compliance, describe the actual behavior.
  • Instead of IVDA or alcoholic, use opiate use disorder, alcohol use disorder or more generally, substance use disorder.

April 2, 2021
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