Recently told at work that patients will have access to their entire charts including notes and labs/imagings and sometimes, because even reviewed by the physicians. That this was a national rule. Anyone else going through similar changes? How are you planning on dealing with this? will it increase risk of malpractice lawsuits?
It's definitely creating a buzz in hospitals and is going to lead to more questions on the patient end. That said, it's critical you learn to practice appropriate documentation hygiene early in residency. This is not often taught by programs which does residents who aim to start clinical practice a disservice.
First and foremost, understand the primary goal of documentation is reimbursement. What you've written should give specific, unambiguous instructions to those carrying out orders and make sense if medicolegal teams get involved. Simultaneously notifying teams of all the thoughts in your head is nice, but should not detract from the primary goal. If you feel like something can not be clearly conveyed through documentation or is a gray area, pick up the phone and call them. Any desire to "think aloud" or preview your next step in notes (ex. if V/Q scan high probability, we will start Heparin) should only be given as a consultant if you're comfortable with that plan being executed without asking you further. For primary teams, try to limit discussion about differentials to only the highest likely conditions and to not recreate an essay from your clinical reasoning course.
Secondly, yes you should copy forward for your own sanity but get into the habit of going line-through-line to ensure everything (dates, daily plan, data), etc. is up to date and the plan is reflective of today. Attendings will lose trust in you if they actually read your notes before signing them and see "surgery tomorrow" when the surgery was a week ago (not using dates instead of "tomorrow" is a rookie mistake). These appear to be pointless details in the grand scheme, but we've become so complacent that many of our notes are now meaningless. Not saying we need to overhaul the system, but we need to spend the extra second on the details at times.
Last, and most important, any difference of opinion you have with another team should be handled by, as my attending likes to say "picking up the damn phone". Never make disagreements or frustrations with other teams evident in notes. Interns oftentimes document "paged surgery team XYZ, no response" for CYA purposes or take a page out of an RNs playbook and document "RN paged second time, no response". Your hospital ultimately functions as a team. Patients will now be privy to all this drama and it will only serve to decrease their confidence in their healthcare team or give fuel to any litigative efforts when things get put under the microscope retrospectively. When it comes to describing actions of patients, be careful not misrepresent what they say while also not attempting to recreate exact conversations via documentation as your memory may not be as sharp as you think and if wrong, you could be accused of libel or worse, give other teams a false impression of the patient. If a patient refuses blood draws and gives a long convoluted rant as to why, simply document "Patient declined blood draw this AM, was counseled on importance". It's not your job to "warn" other teams. Let them walk in and get their own impression. Its ultimately better for the patient if another team can convince the patient to do the right thing as opposed to putting a false label on the patient to try to spare another team a minor inconvenience.
Overall:
1.) Limit your differentials to most likely as a primary team and as consultants, conveying what to do and how (doses, duration) is more important than conveying what's possible. If staff feel the need to pontificate in prose about how this is a challenging case, let them do that in their staff addendum.
2.) Avoid voicing any disagreements/frustrations you have with another team in your notes. It's immature and will only serve to hurt your hospital.
3.) Document a patient's behavior only if its directly pertinent to your exam or plan. State objective information and avoid any commentary to avoid false impressions.
