The subject of clinician note taking in the EHR has gained attention in recent months, as CMS on June 30 began enforcing its interoperability rule, which allows patients to read what their providers have written in their medical records.
The study examined 600 notes that 138 clinicians took for 507 patients. The research team identified five major themes of stigmatizing note taking:
- Questioning a patient’s credibility
- Expressing disapproval of a patient’s reasoning or self-care
- Stereotyping by a patient’s race or social class
- Portraying a patient as difficult
- Emphasizing physician authority over a patient
