Skip to main content

Military Health System

Test of Sitewide Banner

This is a test of the sitewide banner capability. In the case of an emergency, site visitors would be able to visit the news page for addition information.

'Open Notes' Approach Builds Stronger Provider-Patient Relationships

Image of Open notes offer many evidence-based advantages through mutual communication, understanding, and collaboration. Open notes offer many evidence-based advantages through mutual communication, understanding, and collaboration.

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...

Effective Health IT Reduces Burnout, Improves Patient Care

Article
5/25/2023
Effective Health IT Reduces Burnout, Improves Patient Care

Information technology and its intersection with military health care was at the forefront of a key discussion at the annual Healthcare Information and Management Systems Society conference, held in Chicago, Illinois, from April 17 to 21.

Find Answers to Your Health Care Questions through MHS GENESIS

Article
5/19/2023
U.S. Air Force Staff Sgt. Destani Alvarado, 81st Diagnostic and Therapeutics’ Squadron radiology noncommissioned officer in charge, and U.S. Air Force Staff Sgt. Michael Wallace, 81st MDTS radiology floor manager, examine patients records through the Military Health System GENESIS at the medical center, Keesler Air Force Base, Biloxi, Mississippi, on Jan. 6, 2023. MHS GENESIS features a health library where patients can find any information about their health. (U.S. Air Force Airman 1st Class Trenten Walters)

The MHS GENESIS health library gives patients the ability to search for almost anything they would like to know about their health.

Lab Professionals Play Key Role in Public Health and Patient Care

Article
5/2/2023
Lab Professionals Play Key Role in Public Health and Patient Care

Lab professionals provide value to the MHS and DHA communities.

Living Overseas? Here’s How TRICARE Covers Telemedicine

Article
4/18/2023
Living Overseas? Here’s How TRICARE Covers Telemedicine

Do you live overseas and need health care? Depending on the country you’re in, you may be able to get telemedicine care from the comfort of your home.

Q&A: Getting Urgent Care With TRICARE

Article
4/11/2023
Q&A: Getting Urgent Care With TRICARE

Getting sick or injured is never convenient. Fortunately, getting urgent care can take away some of the inconvenience of minor illnesses and injuries.

5 Reasons to Download MyCare Overseas App

Article
4/6/2023
5 Reasons to Download MyCare Overseas App

If you live overseas, the MyCare Overseas app makes it easy to manage your health care at home and on the go.

COVID-19 Registry Provides Pandemic Response Insights, Optimizes Patient Care

Article
3/29/2023
Navy Chief Navy Counselor Agnieszka Grzelczyk assigned to Navy Talent Acquisition Group Philadelphia received the COVID-19 vaccine at Naval Weapons Station Earle in March 2021.

The COVID-19 registry provides the capability to look at treatments and outcomes and is used in conjunction with other larger data sources, enabling improved clinical decision making and better patient outcomes.

COVID-19 Registry Provides Pandemic Response Insights, Optimizes Patient Care

Article
3/28/2023
COVID-19 Registry Provides Pandemic Response Insights, Optimizes Patient Care

Prior to the pandemic, the DOD began deploying MHS GENESIS, the new federal electronic health record, to improve health care outcomes for our service members, veterans, and their families. Critical enterprise needs quickly came to light to combat the impacts of the COVID-19 disease.

Federal EHR Patient Safety Outperforms Legacy, Per Industry Standards

Article
3/7/2023
U.S. Air Force Tech. Sgt. Anthony Iannicello, 8th Health Care Operations Squadron, pharmacy noncommissioned officer in charge, prepares to issue medication to a patient at Kunsan Air Base, Republic of Korea, on Oct. 13, 2022. (Credit: Senior Airman Shannon Braaten 8th Fighter Wing Public Affairs)

The single, common federal electronic health record (EHR) continues to enhance user outcomes and patient safety with results from industry-standard testing showing improvement over legacy systems for clinical decision support tools related to medication safety.

Virtual Education Center Provides Health Information to Patients

Article
3/6/2023
U.S. Army Sgt. Henry Gross, a radiology specialist, drags a simulated patient to safety during Brooke Army Medical Center’s NCO and Soldier of the Year competition at Camp Bullis, Texas, in 2019. The Defense Health Agency’s Virtual Education Center will provide service members with the health and medical information they need to stay ready for the mission.  (U.S. Army photo by Jason W. Edwards)

The DHA has launched a new online tool for physicians. Find out how it could help you more easily navigate the processes involved in accessing your medical and health information.

DHA Supports National Guard and Reserve Deployment Health Needs

Article
2/27/2023
U.S. Navy Chief Information Systems Technician Caleb Korrell, from Cheyenne Wells, Colorado, has his blood drawn by U,S, Navy Hospitalman Jaysean Sales, from Los Angeles, during a physical health assessment rodeo in the hangar bay on Sept. 23, 2022. The Reserve Health Readiness Program helps maintain readiness and satisfy key deployment requirements by providing medical and dental services to all National Guard, Reserve and active duty service members. (Photo by U.S. Navy Spec. 2nd Class Zack Guth)

The Reserve Health Readiness Program (RHRP) helps supplement the reserve component’s readiness mission and satisfy key deployment requirements by providing medical and dental services to all reserve components and active duty members serving in remote locations.

DHA Director: Technology Helps to “Meet the Patients Where They Are”

Article
2/17/2023
DHA Director Lt. Gen. Telita Crosland speaking at a podium

DHA Director Lt. Gen. Crosland discussed her priorities and the burgeoning role of technology at DHA and within the wider MHS.

DHA Deploys MHS GENESIS to More Hospitals & Clinics

Article
2/10/2023
Military personnel at ribbon cutting ceremony

MHS GENESIS adds 11 more military hospitals and clinics with Waves DRUM & PORTSMOUTH.

Operating at Speed of Relevance, Key to Great Outcomes, DHA’s Maturation

Article
11/21/2022
Photo of U.S. Army Lt. Gen. (Dr.) Ronald Place, Christianne Witten, and DHA Senior Enlisted Leader Command Sgt. Maj. Michael Gragg

DHA’s reputation built on speed of relevance in COVID pandemic, which helped it mature as an operational combat support agency.

MHS GENESIS Reaches Significant Operational Milestone

Article
10/27/2022
A man holds an MHS GENESIS sign.

MHS GENESIS reaches more and more military beneficiaries.

Page 1 of 4 , showing items 1 - 15
First < 1 2 3 4 > Last 
Refine your search
Last Updated: January 31, 2023
Follow us on Instagram Follow us on LinkedIn Follow us on Facebook Follow us on Twitter Follow us on YouTube Sign up on GovDelivery