Although there are provisions written into the Cures Act that allow doctors to censor information and prevent a patient from seeing it, many physicians are either not aware of this option or do not know how to use it. “There are often no clear guidelines on when censoring is appropriate,” Dr. Gowda said. “For example, there are exceptions to patients having immediate access to their chart if it would result in harm to the patient, but harm is not clearly defined and doesn’t always refer to emotional harm—as in learning that you had a miscarriage via a radiology report or ED note.

“I think increased awareness of what patients may access and knowing the appropriate steps physicians can take to censor information when needed will help improve communication,” Dr. Gowda continued. “I think this responsibility often falls on the hospital administration to clearly distribute these guidelines.” 

Charting in a New Climate

Now that patients can view physicians’ clinical notes, should doctors adjust their charting habits? Most say little change should be necessary, as clinical notes are still meant for multiple audiences, including other clinicians as well as billing, compliance and medicolegal departments. “I still chart from a medicolegal perspective and to help other providers understand my decision making process,” said Dr. Gowda.

In charting, accuracy has always been paramount. With the new law in place, patients are more inclined to scour their charts in search of errors to report. “There is literature out there, a primary care physicians study, regarding patients who do this,” said Dr. Yore.¹ “We need to be aware of that those patients are going to contact us to say, ’This is wrong, please fix it.’ And if it is wrong, we need to be open to amending our charts.”

Some physicians have expressed concern that patient accessibility to their notes may open them up to harsh and unjustified criticism as every recorded remark and observation is scrutinized. Dr. Yore’s advice: “If you’re not comfortable with your chart being blown up into a 4 × 6 poster in front of a jury, you shouldn’t be putting it in the medical record.” She cautions colleagues to be mindful of the language used in charts and how people are going to perceive it. “This is particularly relevant in the emergency department, where we see a lot of people with substance abuse issues and mental health issues, marginalized people, homeless people, people of different racial, gender/sexual identities, etc.,” she said. “It’s easy to inadvertently—or even as a result of not caring—use language that isn’t appropriate. For instance, you can describe someone as being ’drunk,’ but that’s not exactly neutral language. A suitable description of this patient might read, ’They had a wide, shuffling gait, and speech was slurred.’ This way, you haven’t exposed yourself as coming into that interaction with a set of implicit biases.”