Open notes sounds great, but will a provider’s documentation change?

Background: The effects of shared clinical notes on patients, care partners, and clinicians (“open notes”) were first studied as a demonstration project in 2010. Since then, multiple studies have shown clinicians agree shared progress notes are beneficial to patients, and patients and care partners report benefits from reading notes. To determine if implementing open notes at a hematology/oncology practice changed providers’ documentation style, we assessed the length and readability of clinicians’ notes before and after open notes implementation at an academic medical center in Boston, MA.

Methods: We analyzed 143,888 notes from 60 hematology/oncology clinicians before and after the open notes debut at Beth Israel Deaconess Medical Center, from January 1, 2012, to September 1, 2016. We measured the providers’ (medical doctor/nurse practitioner) documentation styles by analyzing character length, the number of addenda, note entry mode (dictated vs. typed) and note readability. Measur...