Patient-centric medical notes: Identifying areas for improvement in the age of open medical records

Objective: Patients are increasingly provided facilitated access to their medical notes. Physicians have reported concerns that patients will find notes confusing and offensive, and that typographical errors will appear unprofessional. This exploratory study quantifies the prevalence of potentially confusing or offensive medical language and typographic errors within notes.

Methods: The authors performed a retrospective, cross-sectional review of 400 inpatient History and Physical notes from a tertiary care center. All notes were from admissions to general internal medicine services. Words and phrases of interest were codified into five pre-established categories and subdivisions.

Results: Of 400 notes, 337 notes written by residents and hospitalists were analyzed. The most prevalent characteristics identified per note were General Medical Acronyms (99.1%), Medical Jargon (96.7%), and Typographical Errors (49%). Residents used a greater number of acronyms and abbreviations (p<0.01). All subdivisions within Subjective Descriptors and Mental and Personal Health appeared in less than 20% of notes.

Conclusion: While the place of medical shorthand, jargon, and sensitive history in the note is unlikely to change in the near future, this study identifies typographical errors as a modifiable area for improvement. The examination of medical note language may prove beneficial to the patient-physician relationship in the digital era.