DOctorJay

15+ Year Member
May 8, 2004
3,255
823
Status
Attending Physician
our patients are offered a "clinical summary", includes the A&P of the note but leaves out exam and HPI. I can still hide stuff that I want only other physicians to see which is nice. Forces me to get the note done while they're in the office or we mail them a copy.

Have only had a couple patients ask to have something changed. Overall doesn't affect me much.
 

emd123

7+ Year Member
Feb 25, 2010
4,222
1,497
Status
Attending Physician
I always document in a way I wouldn't mind the chart being read by the patient, a judge, jury, attorney, etc

Why? Because it might.

That doesn't mean I candy coat the chart, make it politically correct or leave out signs of aberrant behavior. But I keep to just the facts.
 
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Gauss

Damnit Jim!
15+ Year Member
Mar 3, 2002
1,277
301
Status
Attending Physician
notes are written to appease billers, insurers, audits, and lawyers. patients will never understand this
 
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epidural man

ASA Member
10+ Year Member
Jun 3, 2007
3,226
902
50
San Diego
Status
Attending Physician
I rotated with a pmr physician who would always say "I am going to say this and this in my note. Does that seem right?" I always thought that was brilliant.
 

hyperalgesia

member
Lifetime Donor
10+ Year Member
Jan 9, 2010
5,802
2,178
Status
Attending Physician
Isn't it a meaningful use requirement to allow pts full access to the notes? At the VA, for the past year, pts have full access to their notes electronically.
 
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