Using OpenNotes in inpatient (hospital) settings: Connecting physician-patient communication with user-centered professional communication

Abstract

This study shares findings of a pilot study involving interviews of patients and/or family members in six inpatient (hospital) services regarding the sharing of physicians' notes during patient hospital stays (the OpenNotes project). The study exemplifies the role of technical communication in hospital settings, specifically how physicians document technical expertise for a range of audiences and purposes through progress notes. In this study, the notes that were shared with patients were not written with patients in mind, and interviewers asked questions about patients' perspectives of themselves as the subject of the notes. Results from the interviews demonstrated that patients and/or family members discussed themes of document use (how they used the notes), readability issues (e.g., abbreviations), involvement (e.g., questions), and physician care (feelings about the care they received). These themes reinforced the idea that patients and family members saw themselves as a reading audience of the notes, even though the notes were not originally intended for them.