The Patient-Centered Approach to Medical Note-Writing

Patients are increasingly accessing their own electronic health record, ushering medical chart notes out of the cloistered purview of clinicians and into the age of transparency. With the recognition that patients are reading what is written about them, there is a need for a comprehensive reference on best practices for writing medical notes in this new era.  

The Patient-Centered Approach to Medical Note-Writing covers important topics including stigmatizing language, the electronic health record, the different parts of a typical medical note, mental health, substance use, difficult encounters, and how to address electronic communication such as test results and patient messages. This book serves as a vital reference for students, residents, fellows and practicing clinicians.

Christopher Wong, MD is an Associate Professor of General Internal Medicine at the University of Washington.  He practices primary care internal medicine at the University of Washington Medical Center, teaching medical students and internal medicine residents.  His academic career has focused on general medical topics, including perioperative medicine, preventive health and primary care training.  He is the co-editor of the first edition of The Perioperative Medicine Consult Handbook (2013) and editor of Primary Care of the Solid Organ Transplant Recipient (2020). 

 

Sara Jackson, MD, MPH is an Associate Professor of General Internal Medicine at the University of Washington.  She practices primary care in an academic outpatient clinic at Harborview Medical Center, which serves the safety-net population of King County, WA.  In addition to patient care, she teaches internal medicine residents in clinic and serves in an administrative role as Associate Medical Director for Ambulatory Clinics at Harborview.  Her scholarly work in the area of health services research has focused upon women's health and equitable health care delivery.  She was involved in the original Open Notes study at the University of Washington in 2010 and has been writing and teaching about experiences with Open Notes since then."