Director, Bioethics Consultation Service Montefiore Einstein Bronx, New York
Abstract: The open notes mandate within the 21st Century Cures Act reshaped healthcare documentation by improving transparency of electronic health records, including clinical notes, for patients. While this shift enhances patient engagement, it also raises concerns about how language in documentation can shape clinical encounters and influence care. Bias—whether implicit or explicit—can be embedded in chart notes, affecting how patients are perceived and treated. Clinical ethicists are well-positioned to address these concerns by promoting documentation practices that foster narrative humility and minimize bias. Thoughtful documentation practices can support the therapeutic relationship and build trust, especially in the age of open notes. This presentation introduces methods for facilitating improved chart notes, particularly through structure note templates and dot phrases. The template and dot phrases incorporate prompts that guide chart note authors in avoiding stigmatizing language, capturing the complexities of patient/family decision-making, and promoting humility and charity in documentation. At the same time, standardization presents challenges. While structured prompts can mitigate bias, they must be flexible enough to accommodate the nuances of individual cases. This presentation will explore that balance, considering how documentation practices can remain both consistent and adaptable. A prototype template and set of dot phrases will be provided, and feedback from the audience will be elicited during the question period. By reflecting on how documentation practices shape patient care and clinical decision-making, this discussion invites consideration of how past approaches inform present challenges and how interdisciplinary perspectives can enhance ethical practice.
Keywords: Open Notes, Implicit Bias in Charting, Narrative Humility
Learning Objectives:
After participating in this conference, attendees should be able to:
Describe the ethical implications of the Open Notes mandate and its impact on patient engagement, therapeutic relationships, and clinician documentation practices.
Identify strategies, including structured note templates and dot phrases, that reduce stigmatizing language and promote humility and transparency in clinical documentation.
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