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Writing clinical documents patients can understand

Overview 

Clinical documents are created for care providers, but they may also be read by patients. Think of each clinical document as one document with many uses.  

  • Clinical documents are a tool for communication between care providers. 
  • Patients can already request access to their health information. Adding clinical documents in MySaskHealthRecord (MSHR) makes it easier for them to access that information.  
  • Giving patients access to their clinical documents can help them better understand and take part in their care. It can also help to build trust between patients and their providers. Most patients will be able to understand the information on their own. Some may need support to understand medical terms or care instructions. 
  • Providers using SCM, Fluency for Transcription/Fluency Mobile or Fluency Flex will be able to exclude clinical documents from MSHR in accordance with HIPA criteria. Self-directed training is available in MyConnection.  
  • Clinical documents completed before rollout will not be added to MSHR. 

Tips for providers

These tips are based on what providers in other jurisdictions have learned from sharing clinical documents with patients.  

  • Be clear and concise.
  • Use direct and simple language when possible.  
  • Remember the patient may read the note. 
  • Avoid jargon or abbreviations when possible. 

Be direct and respectful 

  • Use clear, respectful language – especially when writing about sensitive topics. 
  • Write what you discussed with the patient. Include topics you've talked about during your visit. This helps to reinforce their care plan in the future. 
  • Address sensitive health issues directly and respectfully. Some examples include obesity, malignancy or substance use.  
  • For obesity: consider noting BMI using clear definitions, while also focusing on positive changes the patient has made. 
  • For malignancy, clearly note symptoms of concern and any referrals or tests planned. 
  • For substance use, explain how substance use may be related to the patient’s condition. 

Be positive and supportive 

Use caring, objective language. This can help to overcome denial, destigmatize diagnoses, and even motivate behaviour changes.  

  • Write as though the patient is in the room with you. 
  • Focus on the patient’s strengths and achievements. Use notes to motivate patients and give positive feedback.  
  • Avoid language that might sound judgmental. For example, use "declined" rather than "refused" or "chooses not to" rather than "noncompliant". 
  • Avoid language that might be critical of the patient or another provider. Include information in a constructive way that supports good patient care.  

Include patients in the note-writing process 

  • Treat clinical notes as a communication tool. 
  • Let your patients know they can read their notes in MSHR. 
  • Encourage patients to review their notes. 
  • During the visit, check that the patient understands the information that’s included in the note.  

Engage patients with follow-up clinical notes  

  • Complete notes soon after the visit. 
  • Clearly identify follow-up steps or future actions. 
  • Use notes to support patient understanding, feedback and follow-up.