LETTER RE: Sharing notes with patients: A review of current practice and considerations for neurologists
Nitin K.Sethi, MD, New York-Presbyterian Hospital, New York, NYsethinitinmd@hotmail.com
Submitted March 27, 2017
I read with interest the Yu et al. commentary on sharing office visit notes with patients.1 I often read aloud the last office visit notes to my patient at the time of the follow up visit. I begin this by saying "this is what I documented when I last saw you. Please correct me if I got anything wrong in your history." I have found this helpful in 2 ways. One, it helps to refresh the history, assessment, and plan in my own mind and second, it helps engage the patient and accompanying caregiver in his or her care. My experience with this exercise has been a mixed bag. Some patients compliment me for documenting a comprehensive history, while others berate me for getting their hand dominance wrong, or documenting their alcohol intake or use of illicit drugs. Medicine is a science and you call a spade a spade. Alcoholism is not synonymous with social drinking and I fear that physicians would have to water down their notes just to avoid offending the patient. A physician's office notes should be an accurate, objective and nonjudgmental documentation of the patient rather than a politically-correct one. Lastly a physician should never forget that the office note is a medico-legal document, one which can be produced in court and at times used against him.
Disclosures: N. Sethi serves as Associate Editor for The Eastern Journal of Medicine.
References
1. Yu MM, Weathers AL, Wu AD, Evans DA. Sharing notes with patients.
A review of current practice and considerations for neurologists. Neurol
Clin Pract 2017;7:1-7.
I read with interest the Yu et al. commentary on sharing office visit notes with patients.1 I often read aloud the last office visit notes to my patient at the time of the follow up visit. I begin this by saying "this is what I documented when I last saw you. Please correct me if I got anything wrong in your history." I have found this helpful in 2 ways. One, it helps to refresh the history, assessment, and plan in my own mind and second, it helps engage the patient and accompanying caregiver in his or her care. My experience with this exercise has been a mixed bag. Some patients compliment me for documenting a comprehensive history, while others berate me for getting their hand dominance wrong, or documenting their alcohol intake or use of illicit drugs. Medicine is a science and you call a spade a spade. Alcoholism is not synonymous with social drinking and I fear that physicians would have to water down their notes just to avoid offending the patient. A physician's office notes should be an accurate, objective and nonjudgmental documentation of the patient rather than a politically-correct one. Lastly a physician should never forget that the office note is a medico-legal document, one which can be produced in court and at times used against him.
Disclosures: N. Sethi serves as Associate Editor for The Eastern Journal of Medicine.
References
1. Yu MM, Weathers AL, Wu AD, Evans DA. Sharing notes with patients. A review of current practice and considerations for neurologists. Neurol Clin Pract 2017;7:1-7.