Article
Opening Your Notes: Patient Care Recommendations
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.
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