Educating Medical Trainees About Patient-Centered Documentation in the Time of Open Notes.

Abstract

Communication and clinical documentation are core competencies of medical education. With the adoption of open notes, patients have direct access to what clinicians document in their electronic health records. This has transformed clinical documentation from an administrative record-keeping and billing tool into a form of communication with patients. Students should be taught that notes are an extension of the visit that can impact the patient-physician relationship. In the context of relationship-centered care, where the focus lies on the quality of interactions among patients, clinicians, and the broader care team, the language and tone of documentation take on new significance. Clinical notes that are inclusive, respectful, and reflective of the patient's lived experience can help affirm their role as active participants in their care and strengthen the therapeutic alliance. Conversely, depersonalized, biased, or judgmental language may undermine these relationships and negatively affect outcomes. As educators and clinicians, we must train health professional students not only to document with clinical accuracy but also to write in ways that reflect empathy, reduce bias, and promote shared understanding. Patient-centered documentation is a practical and powerful tool for advancing relationship-centered care and improving the experience of both patients and clinicians.