Am I Ready for My Patients to See Their Records? A Guide to Clinicians on Patient Centered Recovery-Oriented Documentation-View Recording

Video Transcription

Video Summary

The session, led by assistant professors Dr. Mira Bodic and Dr. Peter Steen, explored the implications of the Cures Act, which mandates that healthcare institutions provide patients with real-time access to their medical records. The focus was on how this law impacts psychiatry, urging a shift towards more patient-centered, recovery-oriented note-writing. This discussion included the benefits and challenges of patients having access to their notes, emphasizing the importance of avoiding sensationalist, stigmatizing language, and using person-first terminology. They highlighted the importance of aligning written communication with the patient-provider dynamics observed during consultations, ensuring patients do not feel alienated when accessing their notes.<br /><br />Attendees shared concerns about time constraints in documenting patient interactions, questioning whether the new note-writing requirements would increase administrative burdens. Despite these concerns, the session suggested that improved patient-provider communication could enhance treatment engagement and outcomes.<br /><br />The speakers also addressed handling sensitive information, acknowledging both patient trauma and the potential harm of disclosing specific details without context. They highlighted flexibility within the Cures Act allowing note-blocking when sharing could cause patient harm. The session emphasized consistent, open communication about documentation practices to foster transparency and trust in patient care.<br /><br />Finally, the session suggested that clinicians review institutional policies on note-sharing to better align with the Cures Act's requirements. Overall, adopting a recovery-oriented approach by revising current practices could promote patient autonomy and strengthen therapeutic relationships.

Keywords

Cures Act

real-time access

medical records

psychiatry

patient-centered

note-writing

stigmatizing language

patient-provider communication

administrative burdens

sensitive information

note-blocking

recovery-oriented