Are Patient Notes by Residents Ready for Release to Patients?

Among the arguments made by supporters of the shift from paper to electronic medical records (EMRs) is that the latter will make it much easier for patients to access and review their records and then discuss their care with their physician. But with concerns raised in particular about how patients' may respond to the often sensitive information included in psychiatrists' notes, Simon Kung, M.D., of the Department of Psychiatry and Psychology at the Mayo Clinic, and colleagues investigated whether notes written by PGY-3 to PGY-5 psychiatry residents were in fact ready for release to patients. As they report in the new issue of Academic Psychiatry, in general these notes did not raise concerns about readiness for release to patients.

In this study, 128 outpatient treatment notes by the residents that were not marked as "highly confidential" were reviewed by a psychiatrist and a nonpsychiatrist (a third-year medical student who had completed a psychiatry rotation or an experienced psychiatry recreation therapist). The primary outcome was the question, "Overall, if a patient read this note, do you think they would be offended, confused, alarmed, injured, upset? Is the note written in a respectful tone, with sensitivity to culture, age, gender, sexual orientation, disability?" The researchers found that 70% of the notes were assessed as "no concern" by both reviewers, 23% were of "some concern," and 7% were of "major concern." There was a difference, however, between how the psychiatrists and the nonpsychiatrists perceived the notes, with 94% of nonpsychiatrists rating them as of "no concern" but only 72% of psychiatrists doing so.

Read more about this study in Academic Psychiatry.

(image: gelpi/shutterstock.com)