Back to Top Skip to main content Skip to sub-navigation

'Open Notes' Approach Builds Stronger Provider-Patient Relationships

Image of Open notes offer many evidence-based advantages through mutual communication, understanding, and collaboration. Click to open a larger version of the image. Open notes offer many evidence-based advantages through mutual communication, understanding, and collaboration.

Recommended Content:

Electronic Health Record: MHS GENESIS | Access, Cost, Quality, and Safety | Information for Providers | MHS GENESIS

Improving health outcomes, through better communication and engagement with patients, is a cornerstone of practice in the Military Health System. MHS GENESIS, the Department of Defense's new electronic health record, is helping standardize care delivery of this best practice, specifically through its patient portal. The portal includes the first MHS implementation of the concept of open notes, which enables patients to access the notes providers write to document each clinical encounter.

Open notes offer many evidence-based advantages through mutual communication, understanding, and collaboration. Even so, some providers are a bit cautious about the approach. These clinicians worry that patients might misinterpret or disagree with the note contents, potentially leading to interpersonal friction or adverse clinical outcomes.

Undoubtedly, encouraging patients to explore their providers' perspective on clinical interactions fundamentally changes their relationship with providers. Adapting to open notes is easier than you may think, however, and helps providers meet patients where they are and build stronger, more trusted relationships. Open notes enables two-way communication and feedback that encourages providers and patients to feel that they are not just on the same page, but in the same boat on a shared journey.

Flipping the Script

Traditionally, providers have written their session notes to communicate solely with other providers. Patients might get a copy of their record but they rarely if ever read it, often because their providers don't encourage them to and they have to wade through dense jargon if they do. Open notes flips that script by giving patients on-demand access to their providers' observations and instructions and encourages clear dialogue about that content.

As providers, we can encourage patients to take advantage of open notes in each session by asking, "Did you read the note from the last appointment? If so, was there anything that wasn't clear or that you have questions about?"

The patient can read the note and say, "Oh, I have to stop this medication and start this one." They can clarify, "Hey, the note says this, but that's not accurate," or ask, "I need to understand, what did you mean by that?"

A Matter of Trust

Open notes provides a crucial opportunity to ensure the medical record is complete, accurate, and mutually understood. It's not uncommon for a provider to think that they communicated one treatment plan and the patient to hear something else. Every provider has been a patient at some point, and we have all had times where we a) forgot important questions we wanted to ask and b) may not remember what our providers told us.

Open notes also empowers patients and providers to deepen their relationship and their bond of trust. Preserving that trust is especially important now that patients come to visits often having researched their symptoms and possible conditions and treatments. If what you say doesn't match up to what they have seen online, they may have less confidence in you or your clinical abilities.

Trust is at the core of all provider-patient relationships. Ultimately, the success of the treatment plan is not what you as a provider say or recommend – it's what the patient actually decides to do with it based on their trust in you.

Opportunities to Learn

Open notes can also augment patient education. The notes can refer to websites and other materials that patients can review as part of the treatment plan – or even provide homework for patients to do between appointments.

The Defense Health Agency has many resources to help MHS providers learn how to write open notes as well, including this webinar. Three tips you can easily incorporate into writing open notes now are:

  1. Put yourself in the role of the patient. What would you want to know about the provider's observations and recommendations, especially in the diagnostic assessment and treatment plan that you would want to read later? What would you want to share with your family and support network?
  2. Use plain language without medical or military jargon. Patients are only going to improve as much as they understand the treatment plan – and how are they going to comply with any of it if they can't understand what it says?
  3. Include only the information that needs to be there. Be focused and concise, including information that supports the diagnosis and treatment plan and omitting unnecessary personal details.

A Sample Open Note

Let's say you've met with a patient who's having a relationship issue. In your open note about the conversation, don't share the nitty-gritty details of an argument the patient had and who said what to whom.

Instead, you could write something like, "Patient discussed some challenges in their relationship, and we explored various ways of improving communication in that relationship. Patient left with the following tools, which I asked them to practice going forward." If you're a follow-on provider, you can see that the patient had some relationship difficulties and has a treatment plan in place. If you need the specifics, you can ask the patient.

Think of an open note as repeating the high-level takeaways from your meeting, which the patient can review each time they read it. By treating every encounter note as an open note, you can be confident you are following a best practice becoming more widespread every day. Open notes offers the opportunity for you as a provider to demonstrate your commitment to improving outcomes by building patient engagement, one note at a time.

You also may be interested in...

MHS GENESIS Patient Portal expands new features

Article
4/5/2021
Military health personnel wearing a face mask looking at a computer screen

The MHS GENESIS patient portal is readying new features and expanding existing ones, including its online library, and has rolled out special COVID-19 capabilities.

Recommended Content:

Electronic Health Record: MHS GENESIS | MHS GENESIS Toolkit | Health Innovation Toolkit

MHS GENESIS MassVax System Rolling Out with COVID-19 Vaccines

Article
3/9/2021
Military personnel wearing face mask sitting in a line waiting for their COVID-19 vaccine

The new MHS GENESIS MassVax record-keeping tool is expediting and simplifying the process of COVID-19 vaccinations across the DOD

Recommended Content:

Coronavirus | COVID-19 Vaccine Efforts | Electronic Health Record: MHS GENESIS | MHS GENESIS Toolkit | Health Innovation Toolkit

What is the MHS GENESIS Patient Portal?

Video
3/3/2021
What is the MHS GENESIS Patient Portal?

Introduction to the MHS GENESIS Patient Portal site

Recommended Content:

Electronic Health Record: MHS GENESIS | MHS GENESIS Toolkit | MHS GENESIS

MHS GENESIS Relocating

Video
3/3/2021
MHS GENESIS Relocating

MHS GENESIS Portal protocols if you are moving to a new duty station that does not offer GENESIS at this time.

Recommended Content:

Electronic Health Record: MHS GENESIS | MHS GENESIS Toolkit | MHS GENESIS

MHS GENESIS Patient Portal Registration

Video
3/3/2021
MHS GENESIS Patient Portal Registration

Registering for the MHS GENESIS Patient Portal

Recommended Content:

Electronic Health Record: MHS GENESIS | MHS GENESIS Toolkit | MHS GENESIS

NMCSD launches MHS GENESIS

Article
3/2/2021
Military personnel wearing face mask standing in front of the Naval Medical Center in San Diego cutting a red ribbon

Naval Medical Center San Diego deploys MHS GENESIS over the weekend.

Recommended Content:

Electronic Health Record: MHS GENESIS | Technology | MHS GENESIS Toolkit

GLWACH prepares for new electronic health record – MHS GENESIS

Article
2/24/2021
A group of military health personnel wearing face masks sitting around a table using laptops

The new EHR goes online April 24, and will provide a single health record for service members, veterans and their families.

Recommended Content:

Electronic Health Record: MHS GENESIS | MHS Quality, Patient Safety, and Access Information (for Patients)

DHA’s IT innovation continues during COVID-19 pandemic

Article
12/31/2020
Image of three military personnel, wearing masks, in front of a computer screen. Click to open a larger version of the image.

IT innovations keep pace despite COVID-19 road blocks.

Recommended Content:

Coronavirus | Research and Innovation | Technology | Electronic Health Record: MHS GENESIS | Coronavirus and the COVID-19 Vaccine

MHS GENESIS offers patients secure access for their healthcare needs

Article
12/28/2020
Image of military personnel, wearing a mask and looking at a computer screen

The Patient Portal is one of the key features and benefits for any beneficiary using MHS GENESIS.

Recommended Content:

Electronic Health Record: MHS GENESIS | MHS GENESIS Toolkit

Top five digital health trends for military medical providers in 2021

Article
12/17/2020
Image of Dr. Pincus with text "Top Five Digital Health Trends for Military Medical Providers in 2021"

One way the MHS will provide...improved care is through DoD’s new electronic health record MHS GENESIS, which will continue its rollout through 2023.

Recommended Content:

Coronavirus | Electronic Health Record: MHS GENESIS

Wave PENDLETON sees more MTFs deploy new electronic health record

Article
12/9/2020
Image of soldier, wearing a mask, in front of a computer screen

“We are returning to regular deployments of MHS GENESIS following a pause brought on by the COVID-19 pandemic."

Recommended Content:

Electronic Health Record: MHS GENESIS | MHS GENESIS Toolkit

Naval Medical Forces Pacific’s commander tours NH Twentynine Palms

Article
11/12/2020
Four military personnel in uniform, wearing masks

Weber was briefed on the implementation of MHS GENESIS...and the hospital's response to COVID-19.

Recommended Content:

Combat Support | Health Readiness | Coronavirus | Electronic Health Record: MHS GENESIS | Readiness Capabilities

MHS GENESIS goes live at Naval Hospital Camp Pendleton

Article
11/2/2020
Four military personnel, wearing masks, standing in front of two computer screens that say "MHS GENESIS."

These SME’s impart invaluable knowledge to new users, enabling a successful go-live evolution

Recommended Content:

Electronic Health Record: MHS GENESIS | MHS GENESIS Toolkit

MHS GENESIS, DoD’s new EHR system, lands at Edwards AFB

Article
10/27/2020
Military personnel standing and sitting at a desk with multiple computer screens

MHS GENESIS is being implemented at DOD hospitals and clinics in a phased approach over the next several years.

Recommended Content:

Electronic Health Record: MHS GENESIS | MHS GENESIS Toolkit

FEHRM expands joint HIE expanding MHS GENESIS’s reach

Article
10/26/2020
Military personnel at desk assisting an Airman with paperwork

This expansion adds a nationwide network of more than 15,000 hospitals and clinics to the 46,000 community partners already part of the joint HIE.

Recommended Content:

Joint Health Information Exchange | MHS GENESIS Toolkit | Electronic Health Record: MHS GENESIS
<< < 1 2 3 4 5  ... > >> 
Showing results 46 - 60 Page 4 of 13

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.