TY  - JOUR
AU  - Vanka, Anita
AU  - Johnston, Katherine T
AU  - Delbanco, Tom
AU  - DesRoches, Catherine M
AU  - Garcia, Annalays
AU  - Salmi, Liz
AU  - Blease, Charlotte
PY  - 2025
DA  - 2025/1/20
TI  - Guidelines for Patient-Centered Documentation in the Era of Open Notes: Qualitative Study
JO  - JMIR Med Educ
SP  - e59301
VL  - 11
KW  - open notes
KW  - patient-centered documentation skills
KW  - medical student education
KW  - 21st Century Cures Act
AB  - Background: Patients in the United States have recently gained federally mandated, free, and ready electronic access to clinicians’ computerized notes in their medical records (“open notes”). This change from longstanding practice can benefit patients in clinically important ways, but studies show some patients feel judged or stigmatized by words or phrases embedded in their records. Therefore, it is imperative that clinicians adopt documentation techniques that help both to empower patients and minimize potential harms. Objective: At a time when open and transparent communication among patients, families, and clinicians can spread more easily throughout medical practice, this inquiry aims to develop informed guidelines for documentation in medical records. Methods: Through a series of focus groups, preliminary guidelines for documentation language in medical records were developed by health professionals and patients. Using a structured focus group decision guide, we conducted 4 group meetings with different sets of 27 participants: physicians experienced with writing open notes (n=5), patients accustomed to reviewing their notes (n=8), medical student educators (n=7), and resident physicians (n=7). To generate themes, we used an iterative coding process. First-order codes were grouped into second-order themes based on the commonality of meanings. Results: The participants identified 10 important guidelines as a preliminary framework for developing notes sensitive to patients’ needs. Conclusions: The process identified 10 discrete themes that can help clinicians use and spread patient-centered documentation. 
SN  - 2369-3762
UR  - https://mededu.jmir.org/2025/1/e59301
UR  - https://doi.org/10.2196/59301
DO  - 10.2196/59301
ID  - info:doi/10.2196/59301
ER  -