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Chapter 21:  Writing the Daily Visit Note

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Introduction, components of the daily visit note.

• Missed Scheduled Visits
• Summary and Objective
• Full Chapter
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As you know from prior chapters, every time a therapist is scheduled to see a patient, there should be documentation that corresponds with that scheduled session, whether it is attended or missed for any reason. Previous chapters have focused on the components present in three of the therapy notes: the initial evaluation, the re-evaluation, and the discharge note. Often, the most frequently used note written is the daily visit note. 1 This chapter addresses the components of the daily visit note that should be used every time you see a patient.

The daily visit note is referred to and known by multiple names, including visit note, encounter note, daily note , or daily visit note . No matter how a particular facility refers to this note, the components it should include are universal. The purpose of the daily visit note is to document the specific implementation of the patient's plan of care, the response to care, and the patient's function and progress in therapy in between formal evaluation, re-evaluations, and discharge. 1

In addition to the basic components that are present in every health record entry, as noted in Chapter 6 , the following components should appear in every daily visit note 1 :

Subjective report from the patient:

New complaints unrelated to underlying referral diagnosis and/or ongoing complaints related to underlying referral diagnosis.

Compliance with prior instruction or home exercise program and any obstacles making it difficult to comply with prescribed instructions.

Report of pain by the patient, including mitigating factors for change in pain.

A list of all objective interventions completed with the patient and/or family/caregivers:

Each intervention completed during the daily visit, including the frequency, intensity, and duration, as applicable.

Education provided to the patient and/or family/caregivers and how well they understand the education:

Instruction regarding equipment the patient is being trained to use and/or issued and the patient's level of independence in using the equipment

Home exercise program, with modifications to previously issued program noted clearly and copies of any new exercises issued attached to daily visit note and the patient's level of independence with the new exercises

Record of any communication between the treating provider and the patient, family/significant other, caregiver(s), other providers

Assessment of the patient's tolerance of/reaction to interventions provided on that date, positive and/or negative, with rationale if negative. It is not enough to state, “tolerated treatment well.” More detail is needed in this area.

Any changes in the patient's impairment, activity limitation, and participation restriction status in relationship to the patient's plan of care.

All factors that result in a modification of the frequency and/or intensity of intervention and progression of goals.

Plan for continued provision of services for the next visit(s) fully documented, including but not limited to:

The interventions with objectives

Progression parameters

Precautions, if indicated.

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Patients now have access to doctor's visit notes: A guide to what's inside

What does your doctor really think about your condition and health concerns? For more than a year now, patients have been able to access and read the observations doctors write down about them during a visit.

The clinical notes can come with surprises. Patients may be amused to find out they’re described by their physician as “well-nourished,” “well-groomed,” “pleasant” or “normal-looking.”

“’He is not ill-appearing or toxic-appearing.’ That’s the best review I’ve ever received,” one man wrote on Twitter after reading his doctor’s notes.

But patients may also be taken aback by comments referring to them as “obese” or mentioning their marijuana use. One woman was shocked when she saw her doctor wrote down that she “seemed overly dramatic,” she complained on Reddit .

As of April 2021, healthcare providers must give patients access to all of the health information in their electronic medical records as part of the 21st Century Cures Act . That includes your doctor’s written comments about your physical condition during a visit, along with any symptoms and what the treatment should be.

The rules don’t apply to psychotherapy notes made during counseling sessions or when doctors believe a patient would harm another person or themselves after reading the information, according to OpenNotes , a non-profit organization based at Beth Israel Deaconess Medical Center in Boston that advocates for greater transparency in healthcare.

Doctors have been both supportive and cautious of the movement. In a 2020 survey of 1,628 clinicians, 74% agreed note sharing was a good idea.

“It does give the patient a lot more ownership of their medical condition because they can see what we’re thinking about, they understand our thought processes a little bit more, and they can see what the options are,” Dr. Sterling Ransone, Jr., a family physician in Deltaville, Virginia, and chair of the American Academy of Family Physicians, told TODAY.

But knowing that patients can now read his notes, Ransone finds he self-censors himself to avoid sounding critical or judgmental of a patient.

“It’s difficult because sometimes you have to leave a note to yourself what your concerns are, but they can cause anxiety with the patient,” he noted. “I can say that it really has changed the way that a lot of physicians write their notes.”

That means more accessible language, less jargon and more caution with certain terms that might offend or upset a patient.

Ransone no longer uses the abbreviation “SOB,” which stands for “short of breath” and instead writes out the full term in his notes. Same with “FU,” which stands for “follow up.”

The American Academy of Family Physicians has also urged doctors to write “patient could not recall” instead of describing them as a “poor historian;” “patient declines” instead of “patient refuses;” and “patient is not doing X” instead of describing them as “non-compliant.”

A guide to your doctor’s note:

The medical note has traditionally included four parts, Ransone said: The subjective findings, or what a patient said they were concerned about; the objective findings, or what the doctor actually observed during the visit; the physician’s assessment after evaluating the patient and the treatment plan.

Doctors are used to jotting down any observations that can offer clues to what’s going on. So writing down that a patient “seemed overly dramatic” can mean the person’s complaint wasn’t consistent with the degree of their symptoms and something else might be the reason for their visit that day, he noted.

Here are other descriptions patients may find in their doctor’s notes:

Well-groomed or pleasant: This can indicate mental status. “If someone comes in and they’re somewhat disheveled, it leads you to wonder why and what do I need to look into?” Ransone said. “Pleasant” means the patient was communicative and responded to social cues, he noted. Patients who are upset or sleepy could have a substance abuse disorder or another reason why they’re having trouble interacting.

Well-developed or well-nourished: “A lot of times when people look at open notes and they’ll say, ‘Well, of course I am. What does this mean?’” Ransone said. “It just means that we checked in our mental checklist… (that) those aren’t things that we need to worry about.” If a person isn’t well-nourished, it might mean they don’t have access to food or their teeth might be in such bad condition that they can’t chew and get nutrition.

Unremarkable: This is a good thing. “Unremarkable is exactly what you want to be when you see a physician,” Ransone said. “I joke with my patients all the time: You want to be the most boring patient that I’ve seen today, because that means we haven’t seen anything that is abnormal that we need to chase down.”

Obese : To a physician, the term means the patient is of a certain weight for their height and frame, which comes with a certain constellation of medical concerns, Ransone said. “There’s a stigma to obesity in society and a lot of patients really don’t want to have that on their charts… but it’s a very important piece of the puzzle for me as I’m trying to help a patient get healthier,” he noted.

Substance use: This isn’t necessarily bad. Doctors will note a patient has an occasional glass of wine, for example, to give them an idea of the person’s alcohol consumption habits. “The way that our society looks at, say, marijuana use has changed a lot over the years, but a lot of people don’t want that included in the medical record,” Ransone said. “I’d like to know if someone is smoking weed because it could affect the medications that I should give them for their health condition.”

Other health observations patients frequently don’t want on their chart include mental health issues such as depression, anxiety or bipolar disorder, he noted.

Some patients have called Ransone to ask that he change something in their note because they see it as a pejorative or they disagree with his assessment, but that doesn’t mean he’s wrong, the doctor noted.

One guide for physicians suggested telling the patient: “I’m sorry you disagree with my assessment. While I can’t change my medical opinion, if you’d like I can add that you disagree with it.”

Patients pointing out factual errors — such as noticing the note referenced a problem in the right knee rather than the left — is a completely different issue. If there's anything inaccurate in your chart, bring it to your doctor's attention.

In fact, patients who read their doctor’s notes may play an important role in finding errors in their records, a 2020 study published in JAMA found.

Ransone encouraged patients who are reading their doctor’s notes to keep the lines of communication with their physician open.

“Don’t necessarily assume the worst when they read things. Realize that a lot of the things that they read are open to interpretation,” he advised.

A. Pawlowski is a TODAY health reporter focusing on health news and features. Previously, she was a writer, producer and editor at CNN.

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What to Consider When Reading Your Medical Notes

• 1 Associate Editor, JAMA

Shared medical visit notes are notes written by clinicians that are made available (“open”) to patients in electronic health records.

Clinicians add medical notes to a patient’s electronic health record following clinical encounters such as office visits. There is no difference between the notes that patients can view and those that clinicians keep on file.

In 2021, new legislation was introduced in the US that required almost all medical notes to be shared with patients. These notes include

History and physical notes

Progress notes

Consultation notes

Procedure notes

Discharge summary notes

Imaging narratives

Laboratory report narratives

Pathology report narratives

There are a few exceptions. Some medical notes that do not need to be shared with patients include psychotherapy notes that are separated from the rest of the medical record, written by any health care professional; information related to a civil, criminal, or administrative action or proceeding; and any note that a doctor perceives may cause harm or danger to a patient.

The goal of note sharing is to increase transparency between clinicians and patients. Some studies have shown that shared medical notes may help patients feel more engaged in their health care, better understand their medical conditions and care plans, and take their medications properly.

Approach to Reading Medical Notes

Patients are typically able to access their notes through a patient portal to their electronic health record. The notes are there for a patient’s consideration and are optional, not required, reading. The main purpose of medical notes is to communicate information among health care professionals, not between doctors and patients. A patient can avoid reading their medical notes if they find that the information causes them too much worry.

When patients do choose to read their medical notes, it is important to approach them in the right way—not as a clinician, but as a patient. You can discuss with your doctors whether or not you plan to read your notes, which may help them put more patient-directed information (such as follow-up instructions) directly in the notes. If you identify anything in your note that concerns you, discuss that information with someone on your health care team.

For More Information

Office of the National Coordinator for Health Information Technology www.healthit.gov/curesrule/

OpenNotes www.opennotes.org/

To find this and other JAMA Patient Pages, go to the For Patients collection at jamanetworkpatientpages.com .

Conflict of Interest Disclosures: None reported.

Source: Delbanco T, Wachenheim D. Open Notes: new federal rules promoting open and transparent communication. Jt Comm J Qual Patient Saf. 2021;47(4):207-209. doi: 10.1016/j.jcjq.2021.02.004

See More About

Jin J. What to Consider When Reading Your Medical Notes. JAMA. 2021;326(17):1756. doi:10.1001/jama.2021.16493

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April 9, 2024

CMS Update on Medical Record Documentation for E/M Services

The world as we knew it

Summary of changes described in this article

In 2018, CMS changed the requirements for using medical student E/M notes by the attending physician. In the 2019 Physician Fee Schedule Final Rule, CMS stated its desire to reduce the burden of documentation on practitioners for E/M services, in both teaching and non-teaching environments. They stated that a clinician no longer had to re-document the history and exam, but could perform those and “review and verify” information entered by other team members, or entered in prior notes. In 2019, CMS updated the section of the Medicare Claims Processing Manual that addressed E/M services in teaching settings, allowing a nurse, resident or the attending to document the attending’s presence during an E/M service. In 2020, CMS made a radical change to documentation requirements, adopting this as a policy,

“Therefore, we proposed to establish a general principle to allow the physician, the PA, or the APRN who furnishes and bills for their professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students or other members of the medical team.” [1]

• CMS has made significant changes in E/M notes to reduce burden on practitioners in the past years.
• CMS is now allowing clinicians to “review and verify” rather than re-document the history and exam. The details are below.

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“Copy-Pasting. Copy-pasting, also known as cloning, enables users to select information from one source and replicate it in another location. When doctors, nurses, or other clinicians copy-paste information but fail to update it or ensure accuracy, inaccurate information may enter the patient’s medical record and inappropriate charges may be billed to patients and third-party health care payers. Furthermore, inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.” [2]

Read the OIG report

CMS responded that it agreed that additional guidance was needed and that it intended to work with its contractors in the development of effective guidance. To my knowledge, that guidance was never released.

• The OIG expressed concern about copy/paste and over-documentation in 2014, but this did not lead to CMS standards about the practice.
• Commercial payers are largely silent, as well.

2019 Easing the burden of documentation

“We proposed to expand this policy to further simplify the documentation of history and exam for established patients such that, for both of these key components, when relevant information is already contained in the medical record, practitioners would only be required to focus their documentation on what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting a defined list of required elements such as review of a specified number of systems and family/social history. Practitioners would still review prior data, update as necessary, and indicate in the medical record that they had done so. Practitioners would conduct clinically relevant and medically necessary elements of history and physical exam, and conform to the general principles of medical record documentation in the 1995 and 1997 guidelines. However, practitioners would not need to re-record these elements (or parts thereof) if there is evidence that the practitioner reviewed and updated the previous information.” [3]

That long-winded paragraph says that a practitioner would not need to re-record history and exam for established patients that they had reviewed and verified from a prior note.

This was verified by a letter from CMS head Seema Verma . Ms. Verma’s letter went further. It said that effective 1-1-2019, not only could the clinician review and verify history and exam, but for both new and established E/M services, specifically,

“Clarify that for both new and established E/M services, a Chief Complaint or other historical information already entered into the record by ancillary staff or patients themselves may simply be reviewed and verified rather than re-entered” [4]

• In 2019, CMS said that for a new or established patient, the billing clinician could “review and verify” information entered into the record by ancillary staff or patients, rather than re-document.
• CMS included “history and exam” as components that could be reviewed from prior entries and verified, not re-documented.
• Section from 2019 rule and letter from Ms. Verma attached to this article

2020 Expanded “Review and verify”

Perhaps the most shocking change came in the Physician Fee Schedule Final Rule in 2020. CMS noted that stakeholders were questioning whether “students” described in the Medicare claims processing manual referred only to medical students, or if that also referred to nurse practitioner and physician assistant students. Advanced practice registered nurses (APRNs) and physician assistants (PAs) told CMS that they will wanted to use the same rules for precepting their students as physicians used when precepting medical students. CMS agreed with them. But, they went farther.

“Therefore, we proposed to establish a general principle to allow the physician, the PA, or the APRN who furnishes and bills for their professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students or other members of the medical team. We explained that this principle would apply across the spectrum of all Medicare-covered services paid under the PFS. We noted that because the proposal is intended to apply broadly, we proposed to amend regulations for teaching physicians, physicians, PAs, and APRNs to add this new flexibility for medical record documentation requirements for professional services furnished by physicians, PAs and APRNs in all settings.” [5]

Read that section in it’s entirety

• In the 2020, CMS established a general principal to allow the physician/NP/PA to review and verify information entered by physicians, residents, nurses, students or other members of the medical team.
• This principle applies broadly for professional services furnished by a physician/NP/PA.

Codes 99202–99215 in 2021, and other E/M services in 2023

In 2021, the AMA changed the documentation requirements for new and established patient visits 99202—99215. Neither history nor exam are required key components in selecting a level of service. This further reduces the burden of documenting a specific level of history and exam. The 2021 CPT book says this regarding history and exam.

“The care team may collect information and the patient or caregiver may supply information directly (eg, by portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in selection of office or other outpatient services.” [6]

• In 2021, for visits reported with codes 99202—99215, history and exam will not be used to select the level of E/M services. This framework was extended to other E/M services in 2023.

What about teaching physicians

CMS began changing the teaching position rules in 2018, with the stipulation about student documentation. The citation from the CMS manual that changed is below.

B. E/M Service Documentation Provided By Students

“Any contribution and participation of a student to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing. Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.” [7]

What this says is the teaching physician must still do the work. But, the teaching physician doesn’t have to re-document the work. It saves re-documentation on the part of the attending, in the same fashion as the attending doesn’t need to re-document all of the resident’s work.

Documentation performed by medical students, advance practice nursing students and physician assistant students:

“Therefore, we propose to establish a general principle to allow the physician, the PA, or the APRN who furnishes and bills for their professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students or other members of the medical team. This principle would apply across the spectrum of all Medicare-covered services paid under the PFS.”

• Now, physician assistant and nurse practitioner students are treated the same way as medical students for documentation purposes.
• Any physician or NPP who bills a service can “review and verify” rather than re-document.
• Includes “information included in the medical record by physicians, residents, nurses, students or other members of the medical team.”

The new rules allow the attending, the resident or the nurse to document the attending’s participation in the care of the patient when performing an E/M service. CMS said they were going to do this in the 2019 Physician Fee Schedule Final Rule, released in November of 2018, but the transmittal wasn’t released until April 26, although there is an effective date of January 1, 2019 and an implementation date of July 1, 2019. The transmittal does not include any of the examples of linking statement that were in the manual for so many years. It is brief—here is the section on E/M.

100.1.1 – Evaluation and Management (E/M) Services (Rev. 4283, Issued: 04- 26-19, Effective: 01-01-19, 07-29-19) A. General Documentation Requirements

Evaluation and Management (E/M) Services – For a given encounter, the selection of the appropriate level of E/M service should be determined according to the code definitions in the American Medical Association’s Current Procedural Terminology (CPT®) book and any applicable documentation guidelines.

For purposes of payment, E/M services billed by teaching physicians require that the medical records must demonstrate:

• That the teaching physician performed the service or was physically present during the key or critical portions of the service when performed by the resident; and
• The participation of the teaching physician in the management of the patient.

The presence of the teaching physician during E/M services may be demonstrated by the notes in the medical records made by physicians, residents, or nurses.

These are significant changes for all practices, including those in academic settings. We hope that our MACs are paying attention to CMS’s intentions and that other payers follow suit.

[1] CMS 2020 Physician Fee Schedule Final Rule

[2] CMS and Its Contractors Have Adopted Few Program Integrity Practices to Address Vulnerabilities in EHRs, January 2014 OEI-01-11-00571.

[3] CMS 2019 Physician Fee Schedule Final Rule, page 572

[4] CMS letter from S. Verma, 2019

[5] 2020 Physician Fee Schedule Final Rule, p. 380

[6] AMA, CPT E/M codes, 2021

[7] Medicare Claims Processing Manual, 100-04, Chapter 12, Section 100

Last revised April 8, 2024 - Betsy Nicoletti Tags: compliance issues

CPT®️️ is a registered trademark of the American Medical Association. Copyright American Medical Association. All rights reserved.

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Patient Access To Medical Records Is Set To Become Mandatory

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Key Takeaways

• Starting in April 2021, the United States' government will require health organizations to share medical records with patients electronically, free of charge.
• Once the mandate goes into effect, patients will be able to see doctors' notes and other information in their electronic medical record.

It’s soon going to be easier to read your doctor's notes from your last visit thanks to a measure to improve patient record transparency. Starting in April 2021, all medical practices will be required to provide patients free access to their medical records. The concept of sharing medical notes is known as OpenNotes.

Under the  21st Century Cures Act , consumers will be able to read notes that recap a visit to the doctor’s office as well as look at test results electronically.

In the past, accessing your doctor's notes could require long wait times and fees. The Health Insurance Portability and Accountability Act (HIPAA) made it legal to review medical records, but it didn't guarantee electronic access.

More than 250 healthcare organizations in the U.S. (including multiple locations within a single system) are already sharing notes with patients digitally.

What Is OpenNotes?

With OpenNotes , doctors share their notes with patients through electronic health records (EHR). Practices and hospitals use various kinds of software for EHRs, such as MyChart. Once the mandated medical transparency measure goes into effect, patients will be able to log in and see their notes.

The mandate was supposed to begin on November 2, 2020, but in the midst of the COVID-19 pandemic, the deadline was extended to April 5, 2021.

Doctor’s notes will include consultations, imaging and lab findings, a patient's medical history, physical exam findings, and documentation from procedures.

Cait DesRoches , executive director of OpenNotes (a group advocating patient note access), explains that patients will have two ways to get their notes. Either the organization will put the notes on the portal automatically or a patient can request that notes be added to the portal.

“The notes are full of great information for patients,” DesRoches tells Verywell. Viewing the notes can help patients recall what they discussed with their doctors during a visit as well as remind them of what they’re supposed to do after an appointment.

“My hope is that organizations will implement this in a really robust way,” DesRoches says. “That’s when the health system will get to the place where they’re seeing the benefits.

What This Means For You

Being able to see notes in an electronic portal also provides patients with the opportunity to ensure that their medical records are accurate. Before the mandate goes into effect in April 2021, talk to your doctor about how you will be able to access your medical record.

Downsides of Data Sharing

The ability to view documentation from medical care sounds like a great opportunity for patients, but some worry that it could create confusion. For physicians, there's also the potential for an increased workload, as they might need to respond to questions that arise when patients see—and question—what's in their notes.

UC San Diego Health launched a pilot program using OpenNotes for primary care patients in 2018. Marlene Millen, MD , a professor and doctor in the UC San Diego Health , told MedicalXpress that she did not see an increase in inquiries from patients when their notes were available.

What To Know About Doctors’ Notes

There are some cases when a doctor does not have to share medical notes with patients. These scenarios are different state by state, as privacy laws vary.

Doctors can withhold medical records if they think releasing the information will lead to physical harm, such as in the case of partner violence or child abuse.

Providers also do not have to share information regarding certain diagnoses that are considered protected, and psychotherapy documentation is not shared. However, other mental health services outside of talk therapy—such as talking to your primary care doctor about depression—are included in the notes.

Depending on the state you live in, DesRoches explains that parents can also view notes of their teen’s doctor visits. Parents might not have access when teens turn a certain age, based on the state. However, the rules don’t supersede state laws on privacy for adolescents.

Evaluating OpenNotes

OpenNotes.org reports that reading doctors' notes benefit patients in many ways and may lead to better health outcomes. According to OpenNotes, patients who are able to review their doctors' notes:

• Are more prepared for visits with their providers
• Can recall their care plans and adhere to treatment, including medication regimens
• Feel more in control of their care
• Have better relationships with their physicians
• Have a better understanding of their health and medical conditions
• Take better care of themselves

Several studies have assessed OpenNotes. A study published in the journal BMJ Open in September 2020 found that medical transparency is a right that is viewed favorably among people in different countries including Canada, Australia, Japan, Chile, Sweden, and the U.S.  

Another study published in the Journal of General Internal Medicine in July 2020 found that patients typically understand their doctor's notes and that the information in their record is accurate.   However, there were several notable disparities, and participants in the study had suggestions for improving the quality of access.

The researchers found that if patients didn’t understand a note or found inaccurate information in their notes, they had less confidence in their doctors.

According to a report in NEJM Catalyst, the ability to exchange information—including requesting information from patients before a visit—has been instrumental during the COVID-19 pandemic.   In addition to sharing notes with patients after a visit, doctors were able to send a pre-visit questionnaire to patients that enabled them to gather more detail before the visit.

“We suspect, for example, that patients and care partners may recall even less of telemedicine encounters than they do after face-to-face office visits," the authors noted. "As a result, they may turn more often to reading their OpenNotes online."

The researchers concluded that once there are patient- and clinician-friendly mechanisms in place for record-sharing, "inviting patients to contribute directly to their records will both support patient engagement and help clinician workflow.”

Advantages and Disadvantages

Wayne Brackin, CEO of  Kidz Medical Services , tells Verywell that it is “fair and reasonable” to expect patients would have access to doctors' notes. However, Brackin is concerned that doctors could “moderate their description in a manner that might affect care,” if they know that the patient or family will have access to records.

Wayne Brackin

To have a layperson, with a more limited vocabulary, or who has English as a second language, read the notes in isolation could lead to misunderstandings.

“This could be particularly sensitive with behavioral health issues," Brackin says, adding that a medical interpreter of sorts could help avoid misunderstandings during the initial record review. The language, abbreviations, and terminology in physician notes can be difficult for trained medical colleagues to interpret, let alone patients.

“To have a layperson, with a more limited vocabulary, or who has English as a second language, read the notes in isolation could lead to misunderstandings,” Brackin says.

Suzanne Leveille, RN, PhD , a professor of nursing at the University of Massachusetts and a member of the OpenNotes.org team tells Verywell that patients are generally enthusiastic about having online access to their office visit notes, but many providers initially expressed concerns that giving patients access to their notes could cause more worry than benefits.

"Our large surveys across health systems have not shown this to be the case. Very few patients report they became worried or confused from reading their notes," says Leveille, who also authored one of the OpenNotes' studies. "Overwhelmingly, patients report they benefit from note reading, for example, that it’s important for taking care of their health, feeling in control of their care, and remembering their plan of care."

While concerns about misunderstandings are not unwarranted, most patients report they are able to understand their notes, and that they have benefitted from viewing them. In cases where patients have been able to spot—and correct—mistakes, they feel not just more empowered, but safer.

"Open notes can improve patient safety," Leveille says. "About 20% of patients pick up errors in the notes and some report the errors to their providers."

Medical Xpress. More US patients to have easy, free access to doctor's notes .

Salmi L, Brudnicki S, Isono M, Riggare S, Rodriquez C, Schaper LK, et al. Six countries, six individuals: resourceful patients navigating medical records in Australia, Canada, Chile, Japan, Sweden and the USA . 2020. BMJ Open. doi:10.1136/bmjopen-2020-037016

Leveille SG, Fitzgerald P, Harcourt K, Dong Z, Bell S, O’Neill S, et al.  Patients evaluate visit notes written by their clinicians: a mixed methods investigation . 2020. J Gen Intern Med. doi:10.1007/s11606-020-06014-7

Kriegel, G, Bell S, Delbanco T, Walker J. Covid-19 as innovation accelerator: cogenerating telemedicine visit notes with patients . May 12, 2020. NEJM Catalyst. doi:10.1056/CAT.20.0154

By Kristen Fischer Kristen Fischer is a journalist who has covered health news for more than a decade. Her work has appeared in outlets like Healthline, Prevention, and HealthDay.

Patient visits can be more effective if much of the information gathering is done ahead of time.

CHRISTINE A. SINSKY, MD, FACP, THOMAS A. SINSKY, MD, FACP, AND ELLIE RAJCEVICH

Fam Pract Manag. 2015;22(6):30-38

Author disclosures: Christine Sinsky is an adviser for Healthfinch, a company that develops prescribing software. No other relevant financial affiliations disclosed.

When you walk in to see your next patient, is all of the necessary information assembled, organized, and ready? Or do you spend the first five to 10 minutes of each appointment determining who the patient is, why he or she is here, which performance measures are due, and what care the patient may have received from another provider, the emergency department, or an urgent care center since his or her last visit?

In our own practice, if the first time we think about a patient is when he or she checks in, we are already behind. 1 – 3 There is a lot to be done at each appointment. Consider that the average family medicine patient age 65 or older presents with four problems per visit and, in our experience, one or more care gaps needing to be addressed. 4 This is more work than a physician can typically handle alone yet is too important to leave to chance.

Pre-visit planning can help make your patient visits run more smoothly, giving you time to focus on what matters most to the patient and even a little time to spare to simply visit with the patient. Furthermore, you may be able to head home an hour earlier, feeling satisfied with the day and a job well-done, knowing that your patients and staff feel the same.

IN THE AUTHORS' OWN WORDS

Dr. Thomas Sinsky and Debra Althaus, RN, discuss some of the benefits that pre-visit planning provides for their practice.

Pre-visit planning

The objective of pre-visit planning is to help the patient and physician conduct the face-to-face visit more effectively by gathering and organizing information ahead of time so they can devote more attention during the visit to interpreting, discussing, and responding to that information.

Pre-visit planning takes place in several steps:

1. Plan forward, or “The next appointment starts today.” 5 The most efficient form of pre-visit planning begins near the end of the previous visit. As the visit draws to a close, the physician and patient decide on next steps, such as planning any lab tests that might be needed before the follow-up appointment. The physician is already familiar with the patient's conditions and medications, so it should take very little time to identify the appropriate tests for the next visit. The patient then may schedule these appointments immediately instead of having to remember to call back in several months to set them up.

In our practice, we use a checklist to help us plan for the next visit. The checklist is part of a form that also includes the date of the patient's last annual exam as well as any upcoming appointments and labs that are already scheduled. This format allows the physician to put today's care and the next visit's care within the context of the patient's ongoing care. The checklist features lab and other test options in three sections: those to be done before the patient leaves today; those due before the next follow-up visit; and those due before the next annual visit. The patient is then given the option at check-out of receiving an automated reminder phone call, text message, or letter closer to the time of the appointment. (The "Post-appointment order sheet" is available in the FPM Toolbox ).

In an effort to be more patient-centered, we've also found that asking the patient when he or she would like to return is an effective way to share decision-making and give patients an active role in their own care. We also believe this approach, combined with the reminder system and pre-visit labs, have helped lower our no-show rate, which is less than 4 percent.

2. Look back . Some practices do not begin pre-visit planning at the end of the current visit. Instead, it starts a week or so before the next visit when a nurse or other staff member looks back over a patient's record and orders any tests indicated by protocol based on the patient's conditions or medications, as well as any instructions the physician left in his or her documentation from the previous visit. Practices that rely on physicians to enter future orders into the electronic health record (EHR) on the day of the visit will sometimes also employ this “look back” process by the clinical staff. Physicians may feel they cannot spare extra minutes at the end of the visit inputting orders when other patients are waiting, so the look-back process ensures the work has been done.

Reviewing the patient's record outside of the office visit requires more time than planning forward, but it is still more efficient than not doing any pre-visit planning.

3. Pre-visit lab testing . Pre-visit lab testing saves time, improves patient engagement in health management, and reduces the amount of work needed to report and respond to results. Some practices arrange for patients to come in several days before the appointment for lab testing. Others arrange for patients to have their blood drawn 15 minutes to an hour before their scheduled appointment and then use point-of-care testing or rapid turnaround of standard lab testing. In both cases, the goal is to time the tests so that the results are available to the patient and physician at the face-to-face visit.

By having the results available during the appointment, patients can be part of the ensuing decision-making and are more likely to adhere to the treatment recommendations than if they received those recommendations later by phone or letter. In addition, the physician and patient can avoid playing phone tag or engaging in several rounds of email after the visit to resolve unanswered questions. One practice found that pre-visit labs saved $25 in overhead per patient visit. 6

Pre-visit labs can also aid safety. Because patients are able to review their test results together with their physician at the appointment, it is less likely that an important result will be overlooked or lost in the system.

4. Pre-visit phone call . Calling the patient ahead of his or her visit can help the clinical team prepare more thoroughly by clarifying the patient's agenda, anticipating any special needs, and completing many of the tasks usually performed during rooming, such as reviewing medications or screening for depression or falling. Some practices reserve pre-visit phone calls for complex patients. A pharmacist or pharmacy technician may also call these patients for in-depth medication reconciliation. In some cases, this process is aided by access to an all-payer claims database, which staff can use to see what medications the patient has actually filled. You can identify and address nonadherence to medication in a non-judgmental way with this approach.

5. Visit preparation . On the day of or the day before a visit, the medical assistant or nurse can do a quick review of the patient's record to see what needs the patient may have during the appointment. For example, they can identify if the patient needs an immunization, a cancer screening, or other prevention measures and close these “care gaps” during the rooming process. Conducting visit prep can be an effective tool in panel management and can positively affect the health of the entire patient population.

6. Pre-visit questionnaire . A pre-visit questionnaire is a list of questions the patient completes either on paper in the waiting room or through an online patient portal from home. See the questionnaire our practice uses .

PRE-VISIT QUESTIONNAIRE

Questions explore the reason for the visit (“What are you hoping to accomplish today?” and “Is there anything else you'd like to work on to improve your health?”), which prevents the situation in which a patient's main goal is revealed just as the physician is about to leave the exam room. Standardized questions applicable to the particular practice, such as screening questions for falls, depression, or domestic abuse, can also be asked. The questionnaire can also be used to update the patient's past, family, and social histories, as well as to conduct a complete review of systems. All of these uses can save the staff, physician, and patient time during the actual visit.

In our own practice, we have a separate pre-visit questionnaire for the Medicare Annual Wellness Visit that mirrors the template in our EHR, which makes it easier for the nurses to upload the information. Some EHRs are designed so that the patients' answers to the pre-visit questionnaire can be imported into the visit note, reducing the amount of data entry required of physicians and clinical staff.

7. Mini-huddle . The nurse or medical assistant often learns important medical and social information during his or her interaction with the patient during rooming. We have found that a brief “mini-huddle” with the physician before the physician meets with the patient can be helpful. The nurse can alert the physician to the patient's concerns (“She is afraid she will lose all strength in her arm”), a change in social situation (“His wife was recently diagnosed with breast cancer, and he is worried”), or a teachable moment (“Her sister just developed diabetes, so she is willing to work more on diet and exercise to prevent this from happening to her”).

Although we have not found many studies measuring the overall financial savings of pre-visit planning, our personal experience is that pre-visit planning definitely reduces the time spent on a patient's care during or after the visit. A rough estimate is that pre-visit planning takes about an hour of nursing time per day and saves about an hour of physician time and up to two hours of nursing time. It also increases the quality of care by identifying agenda items and care needed at the appointment, such as immunizations or cancer screening.

We have received mostly supportive feedback from our patients regarding pre-visit planning. When they leave an appointment, we reserve a time for their next appointment, which they can plan around. We plan ahead to make that next visit meaningful to them. They don't have to wait after the appointment for lab results or instructions based on those results, and they can speak with their physician about those management decisions.

Finding the right strategy for you

Pre-visit planning can take many forms, and practices can choose the ones that make sense for them. Each component adds efficiency and supports a rapid understanding of why the patient is visiting and what his or her comprehensive needs are. An organized system to manage this complexity and volume will allow physicians to relax and truly listen to patients, knowing that the standardized, predictable work of the practice happens correctly by default and resting assured that they have minimized the chance of overlooking an important piece of data.

You can read more about pre-visit planning, pre-visit labs, huddles, pre-appointment questionnaires, and building a culture of team-work at the American Medical Association's practice transformation website .

Sinsky CA, Sinsky TA, Althaus D, Tranel J, Thiltgen M. Practice profile. ‘Core teams’: nurse-physician partnerships provide patient-centered care at an Iowa practice. Health Aff (Millwood) . 2010;29(5):966-968.

Sinsky CA. Improving office practice: working smarter, not harder. Fam Pract Manag . 2006;13(10):28-34.

Kravitz RL. Improvement happens: an interview with Christine Sinsky, MD. J Gen Intern Med . 2010;25(5):474-477.

Beasley JW, Hankey TH, Erickson R, et al. How many problems do family physicians manage at each encounter? A WReN study. Ann Fam Med . 2004;2(5):405-410.

Phrase coined by ThedaCare Health System, a community health system based in Appleton, Wis.

Crocker JB, Lee-Lewandrowski E, Lewandrowski N, Baron J, Gregory K, Lewandrowski K. Implementation of point-of-care testing in an ambulatory practice of an academic medical center. Am J Clin Pathol . 2014;142(5):640-646.

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Seven mistakes to avoid when billing for subsequent visits

Published in the September 2006 issue of Today’s Hospitalist

Related article: ICD-10 surprises in the hospital .

When it comes to billing for subsequent visits (CPT codes 99231-99233), many hospitalists make some relatively simple and “avoidable” mistakes.

Some errors stem from insufficient documentation and can lead to payments being denied or downcoded. Even worse, a pattern of picking the wrong subsequent visit codes may set you up for an audit.

Bill the highest subsequent visit level—99233—only for patients with a deteriorating condition. 

What to do? When billing for a subsequent hospital visit, you need to choose the appropriate level of service based on the patient’s condition and then make sure your documentation supports that choice. Here’s a list of what can go wrong “and some tips to help you avoid mistakes.

Picking the wrong code. One of the most common mistakes hospitalists make is billing for a higher level of subsequent visit than the documentation and service can support.

Bill the highest level “99233 “only for patients with a deteriorating condition, backed up by your diagnosis and documentation. If the patient is deteriorating, you need to say so clearly in your note.

A stable patient, even with multiple chronic conditions, does not qualify for a level 3 subsequent hospital visit. And if you can’t document at least one review of systems (ROS), the highest level of subsequent visit your documentation may support is a level 1 (99231).

“Clustering” subsequent visit codes. Another big mistake is using the wrong billing pattern.

Billing several level 3 (99233) visits in a row followed the next day by a discharge code, for example, could set you up for an audit. As noted above, only unstable patients meet 99233 criteria, and you wouldn’t expect those patients to be discharged the next day. (See “A scenario of subsequent visit codes” for a coding pattern that won’t set off auditor alarms.)

Skimping on history documentation. To bill a subsequent hospital visit, CPT guidelines require you to meet only two of three components: interval history, exam and decision-making.

But giving details in your history of how the patient is responding “such as “worsening,” “uncontrolled,” “stable” or “improving” “can be key indicators of the service level provided. You also need to document new complaints or symptoms to demonstrate decision-making complexity and to help support a higher level of service.

Not restating why you’re seeing the patient. You’ve seen the patient several times during her hospital stay, so you don’t need to keep documenting why you’re seeing the patient, right?

Unfortunately, that’s not the case. Even if your current note appears directly above your documentation for a previous date of service, you must state the reason why you are seeing the patient and the reason for the service to establish medical necessity. Unless the documentation for each date of service can stand alone and support the service billed, your bill for a subsequent visit may be denied.

Being too vague about follow-up. Another frequent documentation error: stating the reason for the visit is “follow-up,” without elaborating on what it is you’re following. Noting “follow-up” without documenting the patient’s specific condition could render the visit non-billable because, again, the medical necessity cannot be justified.

So don’t be vague. When following up on a patient, state “follow-up” and then the condition you’re monitoring, such as “follow-up CHF.”

Not referring specifically to a previous history. Coders or auditors can rely only on your documented notes for the date of service they are reviewing. But they can use history that you’ve previously documented “as long as you’ve specifically referenced the date the history was taken and given an update. A coder or auditor can then apply the previous history toward your level of history in the current note.

To avoid having to restate the previous note’s history, refer to that note directly. Acceptable versions include “history unchanged since [insert the date of the previous service note] or “[previous date of service] history reviewed, no changes except …”

Documenting “noted above” or “history unchanged” without specifically giving the previous note’s date won’t suffice. Another way to improve the quality of your documentation is by updating the ROS obtained when the patient was admitted, as in “ROS unchanged from [insert date of admission] admission note.”

Ignoring daily concurrent care. Concurrent care becomes a real medical necessity issue, especially when several physicians are rounding on the same patient.

Keep in mind that a subsequent hospital visit represents the services provided during an entire day–and that you can bill only one subsequent visit per day. Even if the physicians in your group bill more than one subsequent visit each day, only one subsequent visit bill will be paid.

Make sure your subsequent visit bill for any given date includes all the services rendered by providers of the same specialty within your group. Combine all visits during one calendar day and select the code that reflects the level of all the work provided.

Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at [email protected] . We’ll try to answer your questions in a future issue of Today’s Hospitalist.

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Anticipated Benefits and Concerns of Sharing Hospital Outpatient Visit Notes With Patients (Open Notes) in Dutch Hospitals: Mixed Methods Study

Sharon l janssen.

1 Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands

2 EvA Servicecentrum, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands

Nynke Venema-Taat

Stephanie medlock, associated data.

Physician and patient survey instruments.

The past few years have seen an increase in interest in sharing visit notes with patients. Sharing visit notes with patients is also known as “open notes.” Shared notes are seen as beneficial for patient empowerment and communication, but concerns have also been raised about potential negative effects. Understanding barriers is essential to successful organizational change, but most published studies on the topic come from countries where shared notes are incentivized or legally required.

We aim to gather opinions about sharing outpatient clinic visit notes from patients and hospital physicians in the Netherlands, where there is currently no policy or incentive plan for shared visit notes.

This multimethodological study was conducted in an academic and a nonacademic hospital in the Netherlands. We conducted a survey of patients and doctors in March-April 2019. In addition to the survey, we conducted think-aloud interviews to gather more insight into the reasons behind participants’ answers. We surveyed 350 physicians and 99 patients, and think-aloud interviews were conducted with an additional 13 physicians and 6 patients.

Most patients (81/98, 77%) were interested in viewing their visit notes, whereas most physicians (262/345, 75.9%) were opposed to allowing patients to view their visit notes. Most patients (54/90, 60%) expected the notes to be written in layman’s terms, but most physicians (193/321, 60.1%) did not want to change their writing style to make it more understandable for patients. Doctors raised concerns that reading the note would make patients feel confused and anxious, that the patient would not understand the note, and that shared notes would result in more documentation time or losing a way to communicate with colleagues. Interviews also revealed concerns about documenting sensitive topics such as suspected abuse and unlikely but worrisome differential diagnoses. Physicians also raised concerns that documenting worrisome thoughts elsewhere in the record would result in fragmentation of the patient record. Patients were uncertain if they would understand the notes (46/90, 51%) and, in interviews, raised questions about security and privacy. Physicians did anticipate some benefits, such as the patients remembering the visit better, shared decision-making, and keeping patients informed, but 24% (84/350) indicated that they saw no benefit. Patients anticipated that they would remember the visit better, feel more in control, and better understand their health.

Conclusions

Dutch patients are interested in shared visit notes, but physicians have many concerns that should be addressed if shared notes are pursued. Physicians’ concerns should be addressed before shared notes are implemented. In hospitals where shared notes are implemented, the effects should be monitored (objectively, if possible) to determine whether the concerns raised by our participants have actualized into problems and whether the anticipated benefits are being realized.

Introduction

One of the defining changes in patient care in the past few decades is the rise of the concept of patient empowerment. The World Health Organization defines empowerment as “a process through which people gain greater control over decisions and actions affecting their health” [ 1 ]. The operationalization of empowerment takes many forms, including interventions to improve patients’ knowledge and health literacy, applications and devices for better self-management, and advocating shared decision-making. An important aspect of empowerment is greater transparency in the health care process. This viewpoint is reflected in statements such as the National Academy of Medicine 2001 recommendation that “patients should have unfettered access to their own medical information” [ 2 ], and in Dutch law, which requires that patients be given a copy of their record upon request, and that electronic access should now be offered [ 3 ]. These directives have been interpreted in various ways. Many hospitals and clinics worldwide now offer patients web-based access to information such as current medications and laboratory results. However, a more controversial question is whether access to the medical record should include access to doctors’ free-text visit notes. Free-text visit notes are notes that a clinician writes about a patient’s visit in the patient record, as opposed to structured information such as lab values. Access to visit notes (and not just structured data such as lab results) is viewed as part of a movement toward greater transparency in health care [ 4 ].

The content of visit notes varies, but typically, visit notes contain the doctor’s observations, assessment (including differential diagnoses), and plan for treatment or further diagnostics. In 2010, Beth Israel Deaconess Medical Center captained a study of “open notes,” wherein 114 primary care providers experimented with shared notes by giving patients full access to their visit notes [ 4 ]. The results of this experiment were positive, with patients reporting positive effects and experiences, and clinicians reporting minimal disruption to their work [ 5 ], despite initial concerns about negative effects on documentation and taking too much time from clinicians and staff [ 4 ]. Since then, a number of health care institutions worldwide have adopted shared notes. These studies also report benefits from shared notes, such as patients feeling better prepared for clinic visits [ 6 , 7 ], feeling more in control of their health [ 7 , 8 ], and feeling that they better recall the doctor’s instructions [ 7 , 8 ]. However, some concerns emerged as well: patients reported difficulty understanding the notes [ 7 ], patients were offended by some content in the notes [ 6 , 9 ], or clinicians reported omitting information from the notes out of concern that it might offend the patient [ 8 ].

Most studies are based in the United States [ 6 - 10 ] and a few from Sweden [ 11 ]. In 2015, the United States entered stage 3 of Meaningful Use, which is a federal program that encourages the use of health information technology. Stage 3 requires the adoption of shared notes to receive financial incentives. Similarly, access to clinic notes is considered a right in Sweden, and most regions in Sweden have implemented shared notes in some form [ 12 ]. These incentives may lead to a more positive view of shared notes. The concerns and benefits may be different in other countries due to differences in culture, health care systems, or other differences. In the Netherlands, a patient must be given a copy of his or her full record upon request, but there is no requirement for the visit notes to be made available on the web. Hospitals in the Netherlands must have a patient portal available, so the visit note could be made available via the portal. A pilot study of shared notes has been announced, but the results have not yet been published [ 13 ].

Little is known about Dutch patients’ interest in shared notes, the benefits anticipated by physicians or patients, or their concerns. It is important to understand these barriers before attempting an implementation and to ensure that patients and physicians have realistic expectations of the benefits. Adding the Dutch perspective can help broaden the understanding currently reflected in the literature. Therefore, our aim is to assess the attitudes of patients and physicians regarding shared outpatient visit notes in a Dutch hospital setting and elucidate their anticipated benefits and concerns by means of a survey and interviews.

We chose a multimethodological (mixed methods) approach, using a short quantitative survey to gather opinions from a large number of patients and practitioners and think-aloud interviews to confirm participants’ interpretation of the survey questions and to understand the nuances behind the responses. As sharing notes with inpatients during hospitalization poses additional technical and practical challenges, we focused on shared visit notes in the outpatient setting. Technical challenges include providing equipment to view notes; practical challenges include determining the appropriate delay before releasing notes, providing bedside technical support services, ensuring privacy, and other challenges. The content of inpatient notes also differs from that of outpatient clinic notes. Both benefits and concerns are expected to differ between inpatient and outpatient settings.

Development

The surveys were developed using published surveys on the topic [ 14 - 16 ] as a starting point. One survey contained questions about potential benefits and concerns [ 14 ], whereas the other two investigated only benefits [ 15 , 16 ]. Relevant questions from these studies were identified by one researcher (SLJ) and confirmed by a second researcher (SM). These questions were adapted, and new questions were added by the researchers based on the aims of our study (concerns, benefits, and attitudes toward shared visit notes). The survey was iteratively discussed and revised by the research team until all team members were satisfied with the questions.

Pilot Testing

The patient survey was piloted with health communication experts. The physician survey was piloted with doctors who were familiar with the procedures in the participating hospitals and the electronic patient record but were not eligible as subjects for the survey (ie, not currently practicing in the participating hospitals).

The feedback from the pilot tests were used to make the final survey for the patients (29 questions over 6 pages) and physicians (23 questions over 4 pages).

Participant Selection for Surveys

The physician survey was sent to doctors from both an academic hospital (the same hospital where the patient survey was conducted) and a nonacademic hospital in the same region. Both hospitals use the same electronic health record system. An email was sent to all heads of all outpatient departments at the academic hospital and to a contact person at the nonacademic hospital who was asked to distribute it to the heads of departments there. The heads of the departments were asked to forward the email to all physicians working in their outpatient department. The email contained a short description of the study and the link to the survey. In addition, before sending the email, the study was introduced at a meeting of the heads of the outpatient departments at the academic hospital. The physicians’ survey was deployed on the web, using a custom form written in the PHP (PHP: Hypertext Preprocessor) programming language, and made available for 5 weeks (March 25, 2019, to May 1, 2019). No reminders were sent. Survey responses from the think-aloud interviews (described below) were added to the survey results by hand.

The patient survey was distributed in the outpatient clinic of a large academic hospital in the Netherlands. Adult, Dutch-speaking patients who attended the outpatient clinic were invited in person by a researcher (SLJ) to participate in the survey. Arrangements for the researcher to attend the outpatient clinic were made with the team leaders of the outpatient clinic, who are responsible for personnel in the outpatient clinic. From March 27, 2019, till April 16, 2019, the researcher went to various outpatient departments to hand out the surveys to patients. The researcher invited consecutive patients arriving in the waiting area on the days that she attended. We selected departments to include both older and younger patients, patients with chronic and acute disease, and varying seriousness of their diagnoses. The researcher (SLJ) approached the patient in the waiting rooms and introduced herself, the study, and the duration of the survey (5-10 minutes). If the patient agreed to participate, the researcher handed out the survey on paper and left the patient to fill in the survey. The same method was used to recruit patients for interviews; the first patients from each waiting area who were approached for the survey were asked to complete the survey with the researcher present in a think-aloud interview. Data on patients who declined to participate was not collected. Data from the paper surveys were transcribed to a spreadsheet by one researcher (SLJ).

Aggregation and Coding of Data

The data analysis consisted of simple counts and percentages. Patients and physicians were allowed to skip questions; therefore, we analyzed each question with n equal to the number of responses to that question. Responses to open questions were coded by one researcher (SLJ) using open coding (manifest content analysis), and the codes were discussed with a second researcher (SM).

The introductory text of both the patient and physician surveys informed participants about the study and that all data would be stored and processed anonymously. Both surveys were voluntary, and no incentives were offered to the patients or physicians.

Think-Aloud Interviews

Following the methods of Westerman et al [ 17 ], we asked a subsample of physicians and patients to fill in the survey, and “think aloud” about their reasoning while filling in the answers. The researcher asked prompting questions if the respondent did not explain their answer out loud. All think-aloud interviews were performed by the first author (SLJ), a master’s student in medical informatics. This researcher’s experience with surveys and qualitative research included courses and an internship during her bachelor’s and master’s degrees. The patients and physicians were informed of the name and background of the first author and were informed of the reason for this study and asked to participate anonymously. The researcher had no relationship with the patients or physicians before the study period. All interviews were audio-recorded and transcribed by the first author.

Participant Selection for Think-Aloud Interviews

In the email used to invite physicians to participate in the survey at the academic hospital, doctors were also invited to contact the researchers to participate in an interview. Interviews were continued until saturation was reached in the responses, and all physicians who responded were interviewed.

As part of the process of distributing the surveys, if an extra exam room was available in the outpatient clinic, the researcher invited patients to take the survey in the room and “think aloud” while completing it. We used a purposive sampling method: 1 or 2 patients were invited to be interviewed in each department visited while distributing the surveys until saturation was reached in the interview results.

The transcribed recordings were coded by a single researcher (SLJ) using thematic analysis. A predetermined starting set of codes was used based on the constructs underlying the survey questions. Open coding was used to classify items that did not fit in the predetermined set. Two coded interviews were checked by a second researcher (SM).

The Medical Ethics Committee issued a waiver for this study, indicating that it does not fall under the Human Research Law of the Netherlands and that no further ethical approval is needed. Informed consent was obtained from all subjects.

The survey instruments are given in Multimedia Appendix 1 [ 14 - 16 ] and annotated with the references used in developing the surveys. The original surveys were in Dutch; they were translated to English by a native English speaker (SM).

Physician Survey

Participants.

A total of 350 physicians completed all (321/350, 91.7%) or a part (29/350, 8.2%) of the survey. An additional 15 empty responses (where the survey was viewed but no questions were answered) were excluded. The demographics of the participants are presented in Table 1 . For physicians who were interviewed who had not completed the survey at the time of the interview, their responses to the survey during the interview were counted as part of the survey responses (8/350, 2.2%). Of the two participating hospitals, 72.8% (255/350) were from the academic hospital, and 17.4% (61/350) were from the nonacademic hospital (the remaining 34/350, 9.7% of respondents skipped this item).

Demographic characteristics of the physicians (N=350) a .

a N indicates the total number of participants who filled in any demographic information.

b The n for each question indicate the number of participants who answered that specific question.

Respondents who selected “other department” could fill in a free textbox; the most common department given in this group (11/320, 3.4%) was the pediatric medicine department.

Opinions on Sharing Notes: Physician Survey

Most physicians in this survey would prefer not to share the visit notes with patients (282/345, 81.7%). When asked what information is in the visit notes, physicians indicated that their visit notes contain the anamnesis (343/350, 98%), treatment plan (339/350, 96.8%), diagnosis (328/350, 93.7%), physical examination (325/350, 92.8%), interpretation and/or summary (321/350, 91.7%), differential diagnosis (315/350, 90.0%), laboratory results (314/350, 89.7%), additional examinations (315/350, 90%), and medical history (283/350, 80.8%). The subjects that physicians were most concerned about sharing with patients were the differential diagnosis (196/350, 56%), interpretation and/or summary (162/350, 46.2%), and anamnesis (110/350, 31.4%).

Reasons why the physicians would not like to share the notes or a part of the note with the patients are given in Table 2 . Participants were able to select any number of responses.

Reasons why physicians do not want to share (part of) the visit note (N=350) a .

a The total “N” indicates the total number of physicians who responded to this question.

b Number of participants choosing this response.

We also allowed respondents to fill in free-text reasons why they did not want to share (part of) the visit notes, which were added by 20% (70/350) of respondents. Analysis of these free-text comments underscored concerns about confusing and worrying the patient, especially by reading the differential diagnosis. Doctors pointed out that they often need to consider the possibility of an unlikely but worrisome diagnosis such as cancer or amyotrophic lateral sclerosis (Lou Gehrig disease) and may want to watch for signs of it on diagnostic tests but do not want to discuss it with the patient unless there is a substantial chance that the patient actually has this disease. Doctors also remarked that the notes are a place to record their thoughts so they can pick up their train of thought later on and that these thoughts might not be complete or may later be proven wrong. This is especially problematic when the doctor suspects a sensitive problem, such as abuse or sexually transmitted diseases. The record also functions as a tool to facilitate discussion of these matters with colleagues. Doctors also expressed concern about family members reading the file or that information would be left out or displaced to other parts of the record, thus compromising the quality of care.

Physicians were largely unwilling to write their notes with less jargon and abbreviations (193/321, 60.1%) to make it more understandable for patients. A smaller group of physicians were willing to partly change their writing style (85/321, 26.4%), and the rest were willing to change their writing style (43/321, 13.3%).

Benefits and Concerns: Physician Survey

In addition to asking physicians about their reasons for sharing or not sharing their visit notes, we also asked physicians about the anticipated benefits of sharing notes with patients and about their concerns. Although there is some overlap with reasons for not sharing notes, we asked about them separately as a doctor may have a concern but not consider it a reason to avoid sharing notes. Participants were able to select any number of responses. The results are presented in Tables 3 and ​ and4 4 .

Anticipated benefits according to physicians (N=322) a .

c Patients already have access to laboratory results via the patient portal.

Anticipated concerns according to physicians (N=322 a ).

We also offered a free textbox where physicians could fill in other benefits or concerns, which was filled by 28.8% (93/322) of the participants. Analysis of the free-text responses showed that 23.9% (77/322) of physicians said that they believed that there are no benefits for the patients or physicians. Other comments (16/322, 4.9%) underscored the benefits of increased retention of information, self-efficacy, and the importance of transparency, as well as the concern that patients will not understand what is written.

Patient Survey

A total of 99 patients participated in the survey. The demographics of the respondents are presented in Table 5 .

Demographic characteristics of patients (N=99) a .

a The total “N” indicates the number of participants who filled in any demographic information.

b The “n” value for each question indicates the number of participants who answered that specific question.

Opinions on Sharing Notes: Patient Survey

In contrast to the physicians, most patients found it important (50/90, 56%) or very important (19/90, 21%) to read the visit notes in the patient portal. Patients were most interested in seeing their laboratory results (78/89, 88%), a summary of the visit (71/89, 80%), and the diagnosis or differential diagnosis (60/89, 67%). Other parts that interested patients were the treatment plan (45/89, 51%), medication (41/89, 46%), and physical examination (34/89, 38%).

Patients agreed (27/90, 30%) or strongly agreed (28/90, 31%) that they expected notes to be written in understandable language or layman’s terms if the doctors know that they will be reading the notes. Patients indicated that if they did not understand the notes, they would ask the doctor at the next visit (39/90, 43%), discuss with family or friends (16/90, 18%), call the department (12/90, 13%), or send a message to the doctor (10/90, 11%). We also asked the patients what they would do if they were to see information in the note that they disagreed with or did not expect. Patients indicated that they would ask the doctor about it during the next visit (62/90, 69%), call the department (38/90, 42%), or send a message to the doctor (22/90, 24%).

Patients were also asked about what they would do with the information in the notes, the benefits they anticipate from open notes, and their concerns ( Table 6 ).

Responses to statements on anticipated responses to notes, possible benefits, and concerns about shared notes.

a The “n” value for each statement indicates the number of participants who responded to that specific question.

Physician Interviews

In total, 13 physicians were interviewed. The duration of the physician interviews was 20-25 minutes. The interview participants were 38% (5/13) male and 62% (8/13) female and worked in 10 different departments.

Reasons for Not Wanting to Share Visit Notes: Physician Interviews

Physicians commented on their reasons for not wanting to share the visit notes with patients ( Table 7 ). The most common reason was fear that the information would be confusing or misleading for the patient:

Coded reasons for not sharing visit notes (n=13).

a Number of participants who mentioned a reason classified under this code.

As a dermatologist we know 3000 skin diseases. So for each spot, an experienced doctor could think of 10 to 20 diagnoses. This would be very confusing for the patient.

Physicians also mentioned the need to document sensitive data, including things such as the suspicion of domestic violence:

Now and then you are suspecting domestic violence or something else. Before you will mention it to the authorities, you need to be sure and gather some evidence.

Physicians also mentioned the function of the patient record as a cognitive aid for the diagnostic process and the need to note clinical hunches that may not yet be confirmed:

I don’t have any secrets from my patients, never. So, from that point of view they are allowed to read the notes - but the point is that I need a space for considerations, worries, and fears. You need to write that somewhere.

Benefits and Concerns: Physician Interviews

In addition to the concerns in the structured part of the survey, doctors mentioned two additional concerns. First, notes are sometimes entered by doctors in training, and they may not yet have the skills to communicate in a way that is appropriate for patients. Physicians also mentioned the need to document private conversations with minors and whether their parents would have access to the notes:

One of my patients just turned 18 and she has a worrying family situation. Her dad was very controlling and I think that they will make comments about my interpretation that it is not only her [that has a problem], because her diagnosis is supported by factors such as stressful family situation.

Jargon: Physician Interviews

We asked the physicians if they were willing to write the notes in understandable language for the patients, and 6 of them said no. Four physicians mentioned that jargon is the most efficient way to work for them: “Every higher education, where intellectual effort is needed and everything that has to do with professionalism has jargon.”

Differences in Visit Note Between Departments: Physician Interviews

In total, 3 physicians said that there is a difference between the notes of different departments. The example was given that notes about a fractured hip (orthopedics) are very different from the notes from hematology.

Other Ways to Achieve the Benefits: Physician Interviews

Half of the physicians wanted to have more time and communication with the patient; 3 physicians mentioned that they were writing information on paper during the visit. Physicians also mentioned sharing letters (sent to the general practitioner) or sharing the visit summary as better alternatives.

Patient Interviews

In total, 6 patients were interviewed. The average duration of the patient interviews was 10-15 minutes. Some patients asked if their partner could attend the interview, so in two interviews, nonparticipants were present. Participants were 50% (3/6) female and 50% (3/6) male, falling into five different age categories (ranging from 18-28 years to 70-79 years).

Reasons for Wanting Open Notes: Patient Interviews

All patients who participated in the interviews were interested in seeing the visit notes but named various reasons for being interested ( Table 8 ). The most cited reason was curiosity; the second was feeling that the note was about them, and this itself is a reason to see it: “I would like seeing the notes because it is about me and I think it is very important that I know exactly what happened.” Patients also mentioned that seeing the notes would help them remember what was discussed, especially after receiving bad news from the physician: “Nine out of ten times you will hear the half of what the doctor is saying.” All 6 patients said that they were interested in seeing all parts of the note.

Coded reasons for wanting to access visit notes (n=6).

Use of Medical Jargon: Patient Interviews

Patients also had varied opinions about expecting a note to be in layman’s terms ( Table 9 ); 2 of the patients interviewed believed that the note should be in layman’s terms:

Comments on the use of medical jargon (n=6).

If the note contains a lot of abbreviations than it makes no sense for the patient to read the note because I would not understand half of the note.

However, 2 patients were neutral on the topic, and 2 disagreed:

No, I don’t expect it because the doctors need to have the possibility to talk and speak in their jargon.

Benefits and Concerns: Patient Interviews

In total, 3 patients mentioned privacy as a potential concern with open notes, both in terms of internet security and who might be given access to the notes in addition to the patient themselves (eg, family members or home care workers).

Other Ways to Achieve the Benefits: Patient Interviews

Patients suggested that some of these benefits could be achieved by bringing someone with you to the visit and having good informational leaflets.

Principal Findings

We designed and conducted surveys regarding opinions on shared notes from 350 physicians and 99 patients, and conducted interviews with 13 doctors and 6 patients. Of all participants, 81.7% (282/345) of doctors prefer not to share visit notes with patients. Physicians indicated that nearly all aspects of care appear in the note, and they were particularly concerned about patients reading the differential diagnosis, the interpretation or summary, and the anamnesis. The most common reasons were worries that reading the note would make patients confused and anxious, that the patient will not understand their notes, that the information is not relevant for the patient, and that the note may contain information that has not yet been discussed with the patient. Clinical notes are written using medical jargon, and most physicians (193/321, 60.1%) did not want to change their writing style to make it more understandable for patients. Physicians did anticipate some benefits, such as better patient recall of what was discussed, better shared decision-making, and keeping patients informed. However, 23.9% (77/322) indicated that they saw no benefit in allowing patients to access the visit notes. Physicians also had many concerns (with some overlap with their reasons for not wanting to share notes), including unnecessary confusion and worry for the patient and family, needing more time to answer patient questions and more time for documentation, and more difficulty communicating with colleagues via the notes. The interviews clarified that physicians were concerned about the need to document sensitive information, such as the suspicion of domestic violence, and the need to have a place to document conversations with minors. They also mentioned the function of the patient record as a cognitive aid to sort through unconfirmed thoughts. Physicians were also concerned about patients reading notes written by doctors in training, who might not write things in a way that is appropriate for the patients. In the patient survey, 77% (69/90) of patients found it important or very important to see their visit notes. Patients were most interested in viewing their laboratory results, visit summary, and diagnoses. Most patients (55/90, 60%) expected visit notes to be written in layman’s terms. Most patients indicated that if they had questions, they would ask them at the next visit, although some (12/90, 13%) indicated that they would call the hospital to ask. A higher percentage indicated that they would call (38/90, 42%) or send a note (22/90, 24%) if they found information that they did not agree with or did not expect. Patients saw some potential benefit to reading their notes: they felt they would better remember what was discussed, feel more in control, and better understand their health. Generally, patients did not feel they would worry more, and 49% (44/90) felt they would not find the notes too confusing (although 32/90, 35% were not sure, and 14/90, 16% felt they would find the notes confusing). The patients who were interviewed were mainly interested in seeing the notes out of curiosity and because they felt they have the right to see information that is written about them. Patients also noted that it is difficult to remember everything from the visit, especially after receiving bad news, and reading the notes would help. The patients interviewed also mentioned security and privacy concerns with shared notes.

Strengths and Limitations

A major strength of this study is the use of mixed methods to gather opinions from both physicians and patients. The survey allowed us to gather opinions from a broad sample of physicians and patients, whereas the interviews allowed us to gain insight into the thoughts behind the responses. This gives us a good picture of the current mindset of these two major stakeholder groups. Another strength is the broad sample of participants, with physicians from both an academic and a nonacademic hospital and a variety of departments. However, this study had some important limitations. The survey that we used was not validated; to our knowledge, no validated survey exists on this subject. We created a survey based on the literature and pilot tested it before deploying it, ensuring that the survey questions were clear and complete according to our pilot participants. We cannot determine the response rate because we do not know how many physicians were invited or how many read the invitation email. To ensure anonymity, we did not attempt to prevent the same person from filling in the survey multiple times, although we saw no evidence of this. We also did not document any information about patients who declined to participate in the survey. The age and gender of the physicians who responded were approximately similar to the demographics of physicians in the participating hospitals. The patients who participated were more likely to be female, which might be due to a higher percentage of women in some clinics (eg, gynecology), a general participation bias (as women are generally more likely to participate in surveys or studies [ 18 ]) or may be due to a participation bias in patients who perceived themselves as similar to the researcher who distributed the surveys (who is also female). We did not ask patients about their medical conditions, and waiting rooms were shared between several outpatient clinics. Thus, our method should provide some variety in the medical conditions of patient participants, but we do not know how much. Physicians and patients with strong feelings about shared notes may be more likely to participate. The fact that all the doctors who were interviewed had a predominantly negative impression of shared notes suggests a participation bias in the interviews. Another potential source of bias is that one researcher invited patients to the surveys, entered data from paper surveys, conducted the interviews, and performed the transcribing and coding. However, a sample of the interviews and coding was checked by a second researcher to reduce the risk of bias. No field notes were made during the interviews, and the transcripts were not checked by the participants. Finally, the choice of hospitals was based on convenience, and therefore, the responses might not be representative of all Dutch hospitals. However, we included physicians from 2 centers, one academic and one nonacademic, and succeeded in including participants from a broad sample of departments.

Comparison With Previous Work

Two previous studies have investigated clinicians’ opinions before the implementation of shared notes; both were focused on psychiatric care, one in the United States [ 10 ] and one in Sweden [ 11 ]. In contrast to our study, 82% of participants in the US study were positive about shared notes [ 10 ]. The Swedish study did not explicitly ask participants if they wanted to share their notes [ 11 ]. Participants in both of the aforementioned studies expressed concerns similar to those in our study: causing unnecessary worry for the patient (77% and 58%, respectively), being more confusing than helpful (67% and 53%, respectively), spending more time answering questions outside of visits (46% [ 10 ]) or being contacted with questions (69% [ 11 ]), and details being omitted from the notes (69% [ 10 ]) or being less candid in the documentation (42% [ 11 ]). In addition to the issues raised in previous studies, our physicians also expressed concern that additional time needed for documentation.

One previous study gathered patient opinions before implementation in ophthalmology patients in the United States [ 19 ]. Similar to our patients, those in this earlier study were positive about shared notes (95%). Patients felt that it would help them to better: understand their conditions (95%), remember their care plan (94%), feel more in control (90%), be prepared for visits (89%), and take better care of themselves (84%). Unlike our patients, patients in this study also believed it would help them to take their medications (77%) and rated their own anticipated ability to understand the notes as 7.5 out of 10. Studies conducted after the implementation of shared notes have found that the perceived benefits and concerns were similar to those found before implementation in both clinicians [ 20 - 23 ] and patients [ 6 , 7 , 9 , 12 , 24 - 27 ]. However, all outcome measures in these studies were assessed subjectively, with the exception of Ross and Lin [ 21 ], who found that the number of messages from the patient to the doctor increased by 31% after the implementation of shared notes. Thus, for the most part, we still do not know if the concerns raised in our study are likely to manifest or if the perceived benefits will be realized if shared notes are implemented.

Interpretation and Implications

One important finding in our study is that many patients expect the note to be written in layman’s terms, whereas many physicians do not want to change the way their notes are written to make them more understandable to patients. This mismatch of expectations must be addressed if the benefits of shared notes are to be realized—patients must understand the notes in order for them to have any benefit. However, clinical jargon exists because it is a precise and efficient language for physicians to document findings and communicate with colleagues. Physicians are rightfully concerned that having to include a plain-language explanation of jargon terms with every clinical note would increase documentation time, ultimately adversely affecting patient care. However, a possible solution to this could be the automated interpretation of clinical notes. van Mens et al [ 28 ] have reported promising results in their efforts to translate diagnoses to layman’s terms using SNOMED-CT (Systematized Nomenclature of Medicine-Clinical Terms); similar technology could be used to produce an explanation in layman’s terms while still allowing physicians to communicate effectively with one another.

Another major concern raised by physicians is the need to document sensitive information. This is supported by Erlingsdóttir et al [ 29 ], who also reported concerns about patient privacy and confidentiality in their analysis of 1554 free-text answers from two web surveys conducted among health care providers in Sweden. Examples raised by our participants included the need to document communication with a minor in situations where the parents have mental health issues, the need to document cases of suspected abuse, and the need to document problems that the patient themselves has not yet accepted. Physicians were also concerned about how patients would respond to reading the differential diagnoses, which often contain some worrisome possibilities. Physicians feared that this important information would either be documented in other parts of the record, making it more likely to be missed on subsequent visits, or simply not be documented at all, which poses serious risks for patient care.

Another potential issue raised by our participants was the notes written by trainees. This is supported by Kung et al [ 30 ], who found that 20% of notes written by trainees raised some concerns. Trainees may be more likely to inadvertently use language that is offensive to patients. As part of the learning process, trainees must create a differential diagnosis list. The differential is the part of the notes that our physicians were most worried about sharing, as it often contains at least some alarming (although usually unlikely) possibilities. A possible solution is to document the differential and trainee notes in another part of the record; however, this runs the risk of fragmenting the record and making information more difficult to find. Another risk is that the visit note effectively becomes a note only for patients, with only a cursory summary, and that the “real” notes simply move to another field in the record.

For the most part, the findings from our patient survey and interviews were in line with previous research. In addition to the questions drawn from previous surveys, we asked our participants what they would do if reading the notes raised questions. They indicated that they would most likely search on the internet or ask at the next appointment; only a minority indicated that they would call the clinic or send a message via the patient portal. This may indicate that the increase in workload resulting from sharing visit notes would be manageable. Our patients also raised concerns about security and privacy, both in the technical sense and socially (eg, whether informal caregivers also have access to the notes).

These findings are important for hospitals seeking to implement shared notes, both in the Netherlands and elsewhere. In the Netherlands, the implementation of shared notes would consist of releasing the notes to patients in the patient portal. The concerns raised by the physicians and patients in our study should be investigated and addressed before implementation is attempted. Care should be taken to sincerely address these concerns to avoid maladaptive responses, such as moving clinical documentation to other parts of the record. Particular attention should be paid to departments who have pediatric and adolescent patients, especially in situations where giving parents access to the record may lead to harm to the patient. Differences in the content of visit notes between departments should also be considered, as well as differences between patients (eg, patients with chronic diseases may understand more of the jargon about their disease than patients with acute disease). We should also take note of the benefits that patients and physicians see in sharing the notes and find a solution that best delivers these benefits while avoiding the pitfalls foreseen by our participants.

Future research should investigate these possible solutions, preferably with the measurement of objective outcomes alongside subjective outcomes. Some important outcomes are inherently subjective, such as patients’ trust in the health care system and sense of empowerment. However, the effects on communication and workflow can and should be measured objectively, such as the time needed for documentation, the ability of other physicians to find needed information, and patients’ understanding of their medical situation. Future work should also repeat some of the questions presented in our survey but with an example of a visit note, so that patients are better able to say whether they are interested in the content of the note and can understand it. Future studies could also explore the relationship between factors such as health status and interest in and perceived benefits of open notes. Patients with poor health may have less energy to read notes or may be even more interested in their notes than patients with better health.

This mixed methods study investigated patients’ and physicians’ opinions of shared visit notes in the outpatient clinic setting in the Netherlands. Patients generally favored sharing notes (70/90, 77%), whereas physicians were often opposed (282/345, 81.7%). We found a mismatch between patients’ and physicians’ expectations for the language used in clinical notes; patients expected notes in layman’s terms, whereas physicians need to communicate using precise clinical terms. Physicians raised concerns about documenting sensitive information, worrying patients with clinical suspicions and the differential diagnosis, and poorer communication due to fragmenting of the clinical documentation; patients raised concerns about security and privacy. Patients and a minority of physicians saw potential benefits in providing patients with better insight into their health state and better retention of important information from the patient visit. Hospitals seeking to implement shared notes should investigate and address these concerns, and future work should measure the effects of shared notes (objectively, when possible) to better understand if the concerns manifest as problems and if the anticipated benefits are realized.

Acknowledgments

No external funding was received for this study. The authors would like to thank MG Ros for his assistance and input during this work. They want to thank the colleagues of the EvA Servicecentrum for their support during this work, especially the eHealth team. The authors would also like to thank Dr M Janssen for distributing the physician invitations and the physicians and patients who participated in this study.

Abbreviations

Multimedia appendix 1.

Authors' Contributions: The study design and data collection were performed by SLJ and SM. Access to patients and physicians was arranged by NVT. Data analysis was performed by SLJ. NVT and SM supervised the study.

Conflicts of Interest: None declared.

Hospice Chaplaincy

Initial chaplain visit assessment and documentation examples.

Dr. Saul Ebema

Initial Chaplain Visit Documentatio n

The hospice Chaplain must complete the initial assessment visit no later than 5 calendar days after the patient has been admitted to hospice care.

This initial assessment must identify the psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient ‘s well-being, comfort, and dignity throughout the dying process.

As you may already know, I like the DAROP format. This format stands for five sections that comprise this narrative framework:

• Observations

EXAMPLE ONE

Here is an illustrative example based an 89 year old male with a diagnosis of Alzheimer’s in a Skilled Nursing Facility.

DATA: Patient was identified by facility staff and room number. The plan of care for this visit is Initial spiritual assessment. Patient is an 89-year-old male with a diagnosis of Alzheimer’s. Chaplain encountered patient in his room where he was up in his wheel chair awake and denied pain. Chaplain engaged patient in conversation to help promote self-expression. He seemed confused and forgetful ( this is in relation to his diagnosis ). Chaplain phoned patient’s daughter Alicia for further assessment and support. Chaplain explored her feelings regarding the patient’s declining health. She said she was coping better at this point and denied any needs. She however stated that patient is very spiritual and used to be a deacon in his Baptist church. She said that patient finds encouragement in faith expressions like scripture and prayer.

ACTION: Chaplain validated her feelings and encouraged her to call hospice as needed for further support of which she was appreciative. Because patient was in his room alone, chaplain offered supportive presence to help counter his sense of social isolation and spiritual comfort through scripture and prayer to help sustain his sense of relationship with God.

RESULTS: He seemed to enjoy the attention he got from the one on one visit. His mood changed, he was happy and appeared comforted by prayers and scripture reading as evidenced by his calm appearance.

OBSERVATIONS: Although patient was pleasant during visit, he was very confused and unable to hold a conversational line of thought.

PLAN: Chaplain will visit patient twice a month for supportive presence and spiritual support. The visit frequency will increase as needed.

Email Address

EXAMPLE TWO

Here is an illustrative example based a NON VERBAL 80 year old male with a diagnosis of COPD. Pt is at home with his wife.

DATA: Chaplain met patient at home with his wife ( in a home visit, patient identification seems obvious ). The plan of care for this visit is initial spiritual assessment. Patient is a 80 year old male with a diagnosis of COPD. Patient was sitting up in his bed, awake and remained nonverbal. Chaplain observed for hints of discomfort in the patient and saw no facial gestures or body movements indicating distress, instead he seemed peaceful ( even when the patient is nonverbal or unresponsive, pain has to be assessed ). Chaplain provided emotional support to the wife who seemed overwhelmed with the burdens of the patients care and declining health needs. In her own words, “I feel like I can’t do this alone anymore; none of my children come to help.” She continued to speak about the patient’s health and faith histories. According to the wife, both her and the patient are devote catholic and find a lot of strength from their faith as a coping mechanism.

ACTION: Chaplain legitimized and normalized her feelings to help reduce anxiety. Chaplain helped her realize that crying or being upset are normal reactions that need to be expressed. Chaplain explored with her new ways of coping. Chaplain also updated Hospice Social worker Mary Holmes for further support for the wife in terms of respite care, caregiver or other available resources. The social worker agreed to follow up. Chaplain then moved with her next to the patient and prayed for both to help offer a sense of God’s attentiveness to their situation and reduce anxiety.

RESULTS: The wife was very appreciative of visit and verbalized feeling much better after talking with chaplain. The patient remained peaceful after the prayer.

OBSERVATION: Pt seemed weak and continues to decline. The wife was struggling with caregiver stress and the burden of care.

PLAN: Chaplain will visit three times a month to offer emotional and spiritual support to the wife and patient.

EXAMPLE THREE

This example is based on an 84 year old female with a diagnosis of unspecified severe protein-calorie malnutrition. Patient resides in a nursing home. She has no children and a distant relative is her Power of attorney for healthcare. ( Your documentation should also be tied to the diagnosis that’s why it is important to know the symptoms of the patient’s hospice diagnosis.)

DATA: Patient is an 84 year old female with a diagnosis of unspecified severe protein-calorie malnutrition. Patient was identified by facility staff and name. The plan of care for this visit is initial spiritual assessment. Chaplain encountered patient in her room where she was up in her wheel chair next to her bed. She denied pain. She verbalized having a lack of appetite and no desire to socialize with other residents by the common area who were playing bingo.

ACTION: Chaplain engaged patient in life review to help foster a sense of hope, and meaning. Patient enjoyed talking about her childhood in Chicago, with laughter she spoke about her parents and important lessons they taught her. She spoke about her late husband and their passions for gambling and travel. She also spoke about her career as a nurse at the local hospital which she found fulfilling. Towards the end, she said, “recalling these memories make me realize that I have lived a good life.” Chaplain affirmed her feelings and offered spiritual comfort consistent with her Baptist faith tradition through scripture and prayer. Chaplain also called her Power of attorney for healthcare and left a message. Awaiting return call. Care coordinated with facility RN Julie who said that patient continues to lose weight due to lack of appetite.

RESULTS: After chaplain engaged the patient in life review, she had a strong feeling of gratitude and peace. It made her realize that she had a great life. She was also appreciative of the prayer. In her own words, “I love to pray and used to be one of the prayer warriors at my church.

OBSERVATION: Pt seemed weak and is losing weight due to her lack of appetite and somewhat withdrawn from the other residents. She however enjoyed the one on one time with the chaplain..

PLAN OF CARE: Chaplain will continue to visit patient twice a month with an occasional PRN and needed.

EXAMPLE FOUR

Illustrative example based on a 68-year-old female patient with a hospice diagnosis of congestive heart failure in a skilled nursing facility. .

Data:  Patient was identified by facility staff and name. The plan of care for this visit is Initial spiritual assessment. Patient is a 68-year-old female with a hospice diagnosis of congestive heart failure. Chaplain encountered patient by the dining room where she was up in his wheel chair, leaning to her left side with support pillows as the facility aide was completing feeding her lunch. Patient was coughing after eating and stared into space.

Action : Chaplain greeted patient, held her hand, encouraged eye contact and attempted to engaged her in conversation to help promote self expression. Although her verbal responses were minimal, she seemed confused. Chaplain read scriptures and prayed with patient.

Results:  When chaplain brought up husband’s name, patient began to talk about him as if he were still alive, although he has been deceased for years. Patient appeared comforted by prayers and scripture reading as evidenced by calm affect and closed eyes.

Observations:  Patient coughed after mealtime, leaned to side, and was unable to engage in reality-based conversation.

Plan:  Chaplain will visit patient twice a month to provide supportive presence and spiritual support.

Hospice Chaplaincy is a national 501 (c)(3) nonprofit organization committed to the belief that people from all backgrounds, cultures and faith traditions should experience the end of life in a way that matches their own values and goals. The task of dying is complicated and often confronts us with lots of emotional and physical suffering. Hospice Chaplaincy is dedicated to providing patient advocacy, support, and education services to the public, to create a cultural shift to inform and transform our thinking around the end of life.

Support Hospice Chaplaincy Today with a tax-deductible donation. Every donation regardless of how much it is will make a big difference. 

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6 responses to “Initial Chaplain Visit Assessment and Documentation Examples”

Although I am an Hospice Chaplain, these notes were vey beneficial. However, I am in pursuit of obtaining more patient in need of hospice services or regular Chaplaincy services online (computer to computer) or perhaps Chaplaincy Zoom meetings to enhance my documentation.

Ok, we will be doing a zoom webinar on chaplain documentation very soon.

Send me information on the webinar on chaplain documentation please.

[…] “Initial chaplain visit assessment” […]

Please send me information on the webinar on chaplain documentation. Thanks.

I am an a Hospital and Hospice Chaplain, these notes are really helpful. Will giving good information for my duties en ICU, Hospital and Hospice patients. Daily I have to fill up the hospital chart after my visits, and also help for our Verbatim. visits I am in Doctoral degree in Divinity’s in order to become a head chaplain in the Hospital.

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The independent source for health policy research, polling, and news.

Americans’ Challenges with Health Care Costs

Lunna Lopes , Alex Montero , Marley Presiado , and Liz Hamel Published: Mar 01, 2024

This issue brief was updated on March 1, 2024 to include the latest KFF polling data. 

For many years, KFF polling has found that the high cost of health care is a burden on U.S. families, and that health care costs factor into decisions about insurance coverage and care seeking. These costs and the prospect of unexpected medical bills also rank as the top financial worries for adults and their families, and recent polling shows that lowering out-of-pocket health care costs is by and large the public’s top health care priority. Health care affordability is also one of the top issues that voters want to hear presidential candidates talk about during the 2024 election. This data note summarizes recent KFF polling on the public’s experiences with health care costs. Main takeaways include:

• About half of U.S. adults say it is difficult to afford health care costs, and one in four say they or a family member in their household had problems paying for health care in the past 12 months. Younger adults, those with lower incomes, adults in fair or poor health, and the uninsured are particularly likely to report problems affording health care in the past year.
• The cost of health care can lead some to put off needed care. One in four adults say that in the past 12 months they have skipped or postponed getting health care they needed because of the cost. Notably six in ten uninsured adults (61%) say they went without needed care because of the cost.
• The cost of prescription drugs prevents some people from filling prescriptions. About one in five adults (21%) say they have not filled a prescription because of the cost while a similar share say they have instead opted for over-the-counter alternatives. About one in ten adults say they have cut pills in half or skipped doses of medicine in the last year because of the cost.
• Those who are covered by health insurance are not immune to the burden of health care costs. About half (48%) of insured adults worry about affording their monthly health insurance premium and large shares of adults with employer-sponsored insurance (ESI) and those with Marketplace coverage rate their insurance as “fair” or “poor” when it comes to their monthly premium and to out-of-pocket costs to see a doctor.
• Health care debt is a burden for a large share of Americans. About four in ten adults (41%) report having debt due to medical or dental bills including debts owed to credit cards, collections agencies, family and friends, banks, and other lenders to pay for their health care costs, with disproportionate shares of Black and Hispanic adults, women, parents, those with low incomes, and uninsured adults saying they have health care debt.
• Notable shares of adults still say they are worried about affording medical costs such as unexpected bills, the cost of health care services (including out-of-pocket costs not covered by insurance, such as co-pays and deductibles), prescription drug costs, and long-term care services for themselves or a family member. About three in four adults say they are either “very” or “somewhat worried” about being able to afford unexpected medical bills (74%) or the cost of health care services (73%) for themselves and their families. Additionally, about half of adults would be unable to pay an unexpected medical bill of $500 in full without going into debt.

Difficulty Affording Medical Costs

Many U.S. adults have trouble affording health care costs. While lower income and uninsured adults are the most likely to report this, those with health insurance and those with higher incomes are not immune to the high cost of medical care. About half of U.S. adults say that it is very or somewhat difficult for them to afford their health care costs (47%). Among those under age 65, uninsured adults are much more likely to say affording health care costs is difficult (85%) compared to those with health insurance coverage (47%). Additionally, at least six in ten Black adults (60%) and Hispanic adults (65%) report difficulty affording health care costs compared to about four in ten White adults (39%). Adults in households with annual incomes under $40,000 are more than three times as likely as adults in households with incomes over $90,000 to say it is difficult to afford their health care costs (69% v. 21%). (Source: KFF Health Care Debt Survey: Feb.-Mar. 2022 )

When asked specifically about problems paying for health care in the past year, one in four adults say they or a family member in their household had problems paying for care, including three in ten adults under age 50 and those with lower household incomes (under $40,000). Affording health care is particularly a problem for those who may need it the most as one-third of adults who describe their physical health as “fair” or “poor” say they or a family member had problems paying for health care in the past 12 months. Among uninsured adults, half (49%) say they or a family member in their household had problems paying for health care, including 51% of uninsured adults who say they are in fair or poor health.

The cost of care can also lead some adults to skip or delay seeking services. One-quarter of adults say that in the past 12 months, they have skipped or postponed getting health care they needed because of the cost. The cost of care can also have disproportionate impacts among different groups of people; for instance, women are more likely than men to say they have skipped or postponed getting health care they needed because of the cost (28% vs. 21%). Adults ages 65 and older, most of whom are eligible for health care coverage through Medicare, are much less likely than younger age groups to say they have not gotten health care they needed because of cost.

One in four immigrant adults (22%) say they have skipped or postponed care in the past year, rising to about a third (36%) among those who are uninsured. Seven in ten (69%) of immigrant adults who skipped or postponed care (15% of all immigrant adults) said they did so due to cost or lack of health coverage. (Source: The 2023 KFF/LA Times Survey of Immigrants: Apr.-June 2023 )

Six in ten uninsured adults (61%) say they have skipped or postponed getting health care they needed due to cost. Health insurance, however, does not offer ironclad protection as one in five adults with insurance (21%) still report not getting health care they needed due to cost.

KFF health polling from March 2022 also looked at the specific types of care adults are most likely to report putting off and found that dental services are the most common type of medical care that people report delaying or skipping, with 35% of adults saying they have put it off in the past year due to cost. This is followed by vision services (25%), visits to a doctor’s offices (24%), mental health care (18%), hospital services (14%), and hearing services, including hearing aids (10%). (Source: KFF Health Tracking Poll: March 2022 )

A 2022 KFF report found that people who already have debt due to medical or dental care are disproportionately likely to put off or skip medical care. Half (51%) of adults currently experiencing debt due to medical or dental bills say in the past year, cost has been a probititor to getting the medical test or treatment that was recommended by a doctor. (Source: KFF Health Care Debt Survey: Feb.-Mar. 2022 )

Prescription Drug Costs

For many U.S. adults, prescription drugs are a component of their routine care. More than one in four (28%) adults say it is either “somewhat” or “very difficult” for them to afford to pay for prescription drugs. Affording prescription drugs is particularly difficult for adults who take four or more prescription medications (37%) and those in households with annual incomes under $40,000 (40%). Black and Hispanic adults are also more likely than White adults to say it is difficult for them to afford to pay for prescription drugs. (Source: KFF Health Tracking Poll: July 2023 )

The high cost of prescription drugs also leads some people to cut back on their medications in various ways. About one in five adults (21%) say in the past 12 months they have not filled a prescription because of the cost. A similar share (21%) say they have taken an over-the-counter drug instead of getting a prescription filled – rising to about one third of Hispanic adults (32%) and more than one in four adults (27%) with annual household incomes under $40,000. About one in ten adults say that in the past 12 months they have cut pills in half or skipped doses of medicine due to cost. (Source: KFF Health Tracking Poll: July 2023 )

Health Insurance Cost Ratings

Overall, most insured adults rate their health insurance as “excellent” or “good” when it comes to the amount they have to pay out-of-pocket for their prescriptions (61%), the amount they have to pay out-of-pocket to see a doctor (53%), and the amount they pay monthly for insurance (54%). However, at least three in ten rate their insurance as “fair” or “poor” on each of these metrics, and affordability ratings vary depending on the type of coverage people have.

Adults who have private insurance through employer-sponsored insurance or Marketplace coverage are more likely than those with Medicare or Medicaid to rate their insurance negatively when it comes to their monthly premium, the amount they have to pay out of pocket to see a doctor, and their prescription co-pays. About one in four adults with Medicare give negative ratings to the amount they have to pay each month for insurance and to their out-of-pocket prescription costs, while about one in five give their insurance a negative rating when it comes to their out-of-pocket costs to see a doctor.

Medicaid enrollees are less likely than those with other coverage types to give their insurance negative ratings on these affordability measures (Medicaid does not charge monthly premiums in most states, and copays for covered services, where applied, are required to be nominal.) (Source: KFF Survey of Consumer Experiences with Health Insurance )

Health Care Debt

In June 2022, KFF released an analysis of the KFF Health Care Debt Survey , a companion report to the investigative journalism project on health care debt conducted by KFF Health News and NPR, Diagnosis Debt . This project found that health care debt is a wide-reaching problem in the United States and that 41% of U.S. adults currently have some type of debt due to medical or dental bills from their own or someone else’s care, including about a quarter of adults (24%) who say they have medical or dental bills that are past due or that they are unable to pay, and one in five (21%) who have bills they are paying off over time directly to a provider. One in six (17%) report debt owed to a bank, collection agency, or other lender from loans taken out to pay for medical or dental bills, while similar shares say they have health care debt from bills they put on a credit card and are paying off over time (17%). One in ten report debt owed to a family member or friend from money they borrowed to pay off medical or dental bills.

While four in ten U.S. adults have some type of health care debt, disproportionate shares of lower income adults, the uninsured, Black and Hispanic adults, women, and parents report current debt due to medical or dental bills.

Vulnerabilities and Worries About Health Care and Long-Term Care Costs

A February 2024 KFF Health Tracking Poll shows unexpected medical bills and the cost of health care services are at the top of the list of people’s financial worries, with about three-quarters of the public – and similar shares of insured adults younger than 65 – saying they are at least somewhat worried about affording unexpected medical bills (74%) or the cost of health care services (73%) for themselves and their families. Just over half (55%) of the public say they are “very” or “somewhat worried” about being able to afford their prescription drug costs, while about half (48%) of insured adults say they are worried about affording their monthly health insurance premium.

Worries about health care costs pervade among a majority of adults regardless of their financial situation . Among adults who report difficulty affording their monthly bills, more than eight in ten say they are worried about the cost of health care services (86%) or unexpected medical bills (83%). Among those who report being just able to afford their bills, about eight in ten say they are worried about being able to afford unexpected medical bills (84%) or health care services (83%). And even among adults who say they can afford their bills with money left over, six in ten nonetheless say they are “very” or “somewhat worried” about being able to afford unexpected medical bills (62%) or the cost of health care services (60%) for themselves and their family. (Source: KFF Health Tracking Poll: February 2024 )

Many U.S. adults may be one unexpected medical bill from falling into debt. About half of U.S. adults say they would not be able to pay an unexpected medical bill that came to $500 out of pocket. This includes one in five (19%) who would not be able to pay it at all, 5% who would borrow the money from a bank, payday lender, friends or family to cover the cost, and one in five (21%) who would incur credit card debt in order to pay the bill. Women, those with lower household incomes, Black and Hispanic adults are more likely than their counterparts to say they would be unable to afford this type of bill. (Source: KFF Health Care Debt Survey: Feb.-Mar. 2022 )

Among older adults, the costs of long-term care and support services are also a concern. Almost six in ten (57%) adults 65 and older say they are at least “somewhat anxious” about affording the cost of a nursing home or assisted living facility if they needed it, and half say they feel anxious about being able to afford support services such as paid nurses or aides. These concerns also loom large among those between the ages of 50 and 64, with more than seven in ten saying they feel anxious about affording residential care (73%) and care from paid nurses or aides (72%) if they were to need these services. See The Affordability of Long-Term Care and Support Services: Findings from a KFF Survey for a deeper dive into concerns about the affordability of nursing homes and support services.

• Health Costs
• Racial Equity and Health Policy
• Private Insurance
• Affordability
• High Deductible Plans
• Tracking Poll

Also of Interest

• Health Care Debt In The U.S.: The Broad Consequences Of Medical And Dental Bills
• KFF Health Tracking Poll – March 2022: Economic Concerns and Health Policy, The ACA, and Views of Long-term Care Facilities
• KFF’s Kaiser Health News and NPR Launch Diagnosis: Debt, a Yearlong Reporting Partnership Exploring the Scale, Impact, and Causes of the Health Care Debt Crisis in America
• How Financially Vulnerable are People with Medical Debt?

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Letter to the nation’s teaching hospitals and medical schools

To the nation’s teaching hospitals and medical schools:

Today, the Department of Health and Human Services (the Department), through the Centers for Medicare & Medicaid Services (CMS), released new guidance to reiterate and provide clarity regarding hospital requirements for informed consent from patients as it relates to medical professionals performing sensitive examinations, particularly on patients under anesthesia. Please share this guidance with your members.

The Department is aware of media reports as well as medical and scientific literature highlighting instances where, as part of medical students’ courses of study and training, patients have been subjected to sensitive and intimate examinations – including pelvic, breast, prostate, or rectal examinations – while under anesthesia without proper informed consent being obtained prior to the examination.  It is critically important that hospitals set clear guidelines to ensure providers and trainees performing these examinations first obtain and document informed consent from patients before performing sensitive examinations in all circumstances.  Informed consent includes the right to refuse consent for sensitive examinations conducted for teaching purposes and the right to refuse to consent to any previously unagreed examinations to treatment while under anesthesia.

In addition, the Office for Civil Rights (OCR) investigates complaints alleging that patients’ protected health information was used or disclosed to medical trainees in violation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule.  The HIPAA Privacy Rule safeguards protected health information (PHI) from impermissible use and disclosure and further gives individuals the right to restrict who has access to their PHI, including in scenarios where they may be unconscious during a medical procedure. OCR recently issued a Frequently Asked Questions document explaining this right.

OCR also enforces federal civil rights laws, such as Section 1557 of the Affordable Care Act, which prohibits discrimination on the basis of sex, race, national original, age, and disability.  OCR has previously worked with, and will continue to work with, covered entities to ensure that their policies and practices related to sensitive examinations do not discriminate against patients on any of these bases.

While we recognize that medical training on patients is an important aspect of medical education, this guidance aligns with the standard of care of many major medical organizations, as well as state laws that have enacted explicit protections as well.  Informed consent is the law and essential to maintaining trust in the patient-provider relationship and respecting patients’ autonomy.  We welcome the opportunity to work with providers to promote compliance with existing federal laws and plan to hold a webinar regarding this requirement soon.

Xavier Becerra Secretary, U.S. Department of Health and Human Services

Chiquita Brooks-LaSure Administrator, CMS

Melanie Fontes Rainer Director, OCR

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Vaccine News & Notes — April 2024

Published on Apr 04, 2024

Parents PACK

A little discussed effect of covid-19 infection in children.

About two to six weeks after a COVID-19 infection, a very small number of children experience a condition called multisystem inflammatory syndrome in children, or MIS-C. (Adults can also experience this syndrome in whom it’s called MIS-A.) Affected patients experience fever and one or more symptoms like stomach pain, vomiting or diarrhea; bloodshot eyes; skin rash; or dizziness or lightheadedness. Some symptoms requiring emergency medical attention can also appear, such as trouble breathing, chest pain or pressure, severe abdominal pain, inability to wake up or stay awake, or pale or grayish-blue skin color. MIS-C typically affects multiple organs, including eyes, brain, heart, lungs, kidneys, skin or organs associated with digestion.

MIS-C can occur following any COVID-19 infection (mild, moderate or severe). Early in the pandemic, it became clear that a recent COVID-19 infection increased one’s risk for this condition, so medical professionals have been monitoring cases ever since. A recent report offered some important updates:

• While cases had decreased from their height in late 2020 and early 2021, reports recently increased — coincident with a spike in COVID-19 infections in the fall of 2023.
• During 2023, 117 children were diagnosed with MIS-C. About half of them were admitted to the intensive care unit. Three children died.
• About 8 of every 10 children affected with MIS-C were not vaccinated against COVID-19 even though they were old enough to have been vaccinated.
• Of the vaccinated children who experienced MIS-C, about 6 of 10 had received their vaccine more than one year prior.
• Almost 6 of every 10 children affected had no underlying medical conditions.
• The functioning of the child’s heart was affected in about 3 of every 10 cases. Likewise, about 3 or 4 of every 10 children suffered shock, meaning their organs were not getting enough blood for a period of time.

These findings are important for families to consider, particularly given that many children remain unvaccinated against COVID-19.

Find out more:

• Read the report.
• Find out more about MIS-C and MIS-A.

17 states have had cases of measles in early 2024

Measles, probably the most contagious vaccine-preventable disease, continues to circulate throughout the U.S. As of mid-March 2024, 17 states have reported 64 cases of measles — already surpassing the number reported in all of 2023 (58 cases). Adding to this concern is the steady drumbeat of cases each week. Every week since the beginning of December 2023, at least one case of measles has been reported to the Centers for Disease Control and Prevention (CDC).

• CDC webpage, “Measles Cases and Outbreaks”
• Info and resources about measles from the Vaccine Education Center (VEC)

70 years spent in an iron lung

Have you heard of Paul Alexander? Chances are you have not. Paul passed away on March 11, 2024, at the age of 78. Since the age of 6, Mr. Alexander survived with the use of an iron lung, a machine that many have not heard of, and those who have, often associate the machine with history. An iron lung is a machine designed to help people breathe when their diaphragm no longer functioned due to paralytic polio. The individual lays inside of the machine with only their head sticking out.

Paul’s story is one of inspiration for all he accomplished during his life, including completing college and becoming a lawyer. But his life is also a reminder of a disease that rarely affects children in the U.S. today because of effective vaccinations. Late in his life, Paul had trouble getting parts for his iron lung, and although he had trained his muscles to allow for short periods spent out of the contraption, he still needed it to stay alive when he slept and as he got older, when he needed to again spend most of his time in the machine.

Find out more about Paul’s inspiring story in these articles from The Washington Post or The Guardian or in his memoir, Three Minutes for a Dog: My Life in an Iron Lung .

Find out more about polio and the vaccine from the VEC.

Categories: Parents PACK April 2024 , Vaccine News & Notes

Materials in this section are updated as new information and vaccines become available. The Vaccine Education Center staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family's personal health. You should not use it to replace any relationship with a physician or other qualified healthcare professional. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult your physician or, in serious cases, seek immediate assistance from emergency personnel.