How the healthcare industry can ensure clinical documents are as transparent as possible

Why is transparency important in healthcare?

Healthcare professionals spend their time interacting with patients who are often experiencing some of the most vulnerable times of their lives. Whilst the actual delivery of quality care is undoubtedly important, knowing how to establish a trusting relationship with patients and ensuring they feel comfortable and confident is also essential. In order to do this, the treatment process needs to be transparent. Research has been conducted on the importance of transparency in healthcare, and it has been positively correlated with good outcomes, including improved quality, safety, and efficiency. But how exactly can you achieve good transparency? The answer, as you probably already guessed, lies within clinical documentation. Doctors and other healthcare professionals are continuously reminded of the importance of producing effective clinical documentation, yet so often these records fail to contain the required detail. In fact, it has been recorded that up to 70% of patient records have errors or false information. Improving clinical documentation can contribute to a more effective model of communication, better clinical outcomes, and higher patient satisfaction. By continuously making attempts to improve your documentation, you are facilitating a stronger relationship with patients and a better experience within the healthcare industry. With a few simple strategies, you will be guaranteed to optimize your clinical documentation process and improve the transparency of your delivery of healthcare.

Barriers to medical record transparency

With advancements in technology and the development of data access features like EHRs, you might be wondering why transparency remains an issue. Despite the development of new systems, feedback reports indicate that patients are still finding it difficult to access transparent copies of their medical records and relevant documentation. Whilst physicians and healthcare staff are taking full advantage of EHRs to improve their communication and access documentation, the full capabilities of these systems have not been made available to patients. Additionally, patients who do utilize EHRs to view their medical records, are still impacted by various barriers. Clinical documentation isn’t designed to be read by patients. Records are filled with medical jargon and are structured in a way that is often confusing for practitioners to interpret - let alone patients! There is also the issue of physicians who are reluctant to let their clients read their documents. Perhaps understandably, some practitioners believe if their patients had access to honest notes, they might become angered or upset, leading to a loss of trust and even potentially a lawsuit. Despite the presence of barriers impacting transparency in healthcare, it is essential that practitioners and patients work together to find a solution to these issues. 

5 Effective tips to ensure clinical documentation transparency

So what can you, as a healthcare professional, do to increase the transparency within your clinical documentation? Although the specific methods of physicians will differ, we have collated five strategies that will help you improve your clinical documentation, and strengthen your relationship with patients.

• Reduce the jargon: Given that medical jargon is a significant barrier preventing patients from truly understanding the content within their records, it is your responsibility to reduce this type of language. We understand that you may be used to documenting your patient interactions in a certain way, but medical jargon gets in the way of patients' ability to benefit from access to their records. Reverting back to universally understood language isn’t a difficult change, and it will help improve effective communication. 
• Objectivity: Whilst this may seem like an obvious tip, the importance of remaining objective cannot be overestimated. There will definitely be aspects within your records that are somewhat subjective, including your opinion on a patient’s affect and appearance, but this commentary needs to remain professional at all times. A good way to look at it is by focusing on describing the patient’s behavior rather than making a judgment. Any statement you make should be backed up by some sort of evidence and you should refrain from using words with negative connotations. 
• Consistency: If you are seeing and/or treating a patient, you will most likely write multiple forms of clinical documentation. Because the patient will have access to all of these records, consistency is key. If you use the same formatting techniques for all of your records, patients will find it significantly easier to interpret what you are saying. One of the best ways to achieve consistency is by adopting a template. As I’m sure you are aware, the most commonly used progress note template is known as a SOAP note and it structures documents into four sections: subjective, objective, assessment, and plan. With a consistent structure, patients will understand what sections contain what kind of information, and their ability to navigate records will be simplified.  
• Collaboration: One of the biggest reasons why EHRs lead to good clinical documentation is derived from the inter-practitioner collaboration that they facilitate. Your patient records should be supported by numerous forms of documentation, including labs, radiology, test results, and nursing documentation. This type of collaboration provides a more holistic and thorough overview of a patient’s current health condition, elevating the transparency of clinical documentation. Additionally, collaboration allows patients to access every part of their clinical records from a single space, without needing to go through various platforms.
• Patient portal: The development of patient portals and consequent implementation into healthcare practices has grown significantly in recent years. This is one of the most effective ways to eliminate accessibility barriers for patients. By using a patient portal, clients have 24/7 access to their own records and documentation. Additionally, these portals are usually integrated into a practice’s EMR system, which allows any updates or modifications to occur in real-time. Patients can also utilize the direct communication channel it provides with their physicians, allowing them to raise questions or clarify aspects of their records/treatment that they don’t understand.

What does the future of healthcare transparency look like?

Despite the fact that clinical documentation wasn’t initially designed to be read or consumed by patients, efforts to improve transparency are gradually taking shape. There are various outcomes that are predicted to result from this change, and it is a good idea to remain aware of what these entail. Firstly, it is growing more apparent that the healthcare industry is moving away from a “name and shame” ideology of exposing poor documentation. Ostracizing and judging practitioners leads to more adverse outcomes, and fails to lead to any meaningful change. Instead, there should be a larger focus on making the tools that already exist more available to patients. The widespread functions of EHR systems should be taught to patients, so they can efficiently utilize these platforms to their own advantage. The simple law of demand and supply reinforces the notion that if more patients are accessing and using these systems, then more practitioners will feel the responsibility to make them as accessible as possible. One of the best ways to do this, as mentioned before, is by implementing a patient portal into your practice. This way, patients can have access to pertinent information at any time, from anywhere. Despite the evident barriers to transparency in medical health records, new strategies are being employed by practitioners everywhere to eliminate these and improve the effectiveness of clinical documentation. 

Further Reading:

• Patients and their medical records: It is time to embrace transparency
• Fundamentals of Medical Record Documentation