OpenNotes

Thank you to for recognizing OpenNotes as Patient Experience Program of the Year!

We were honored to be nominated for the award by the community. This award recognizes initiatives that improved or sustained high levels of excellence in patient experience, patient access, and/or patient engagement.

We will continue putting patients at the center of our work and making healthcare more transparent.

Language like "chief complaint," "patient is combative," or "patient is non-compliant," are discouraged in Harvard's new curriculum for writing medical notes.

Instead, students are asked to reflect. Have they ever read their own clinical notes or those of a family member? How did they respond?

Best practices include:

✅ Use person-first language

✅ Refer to your patients as how they want to be identified

✅ Avoid abbreviations and acronyms, especially if not officially approved by the practice

✅ Say what you write, write what you say

✅ Verify past history information before recording it in the note

✅ Avoid words which may convey bias or judgment

✅ Keep physical exam descriptions objective

✅ Empower your patients with encouraging words and clear next steps

✅ Pay close attention to sensitive topics, including but not limited to sexual history, trauma history, substance history, mental health or illness

✅ Write from your perspective

How about you — have you ever read medical notes that felt alarming instead of helpful? How did you respond?

Read more:

Improving Transparency for Patients Through Medical Notes At Harvard Medical School, Dr. Anita Vanka led an effort to create a comprehensive curriculum based on patient-centered documentation practices.

Meet Cait!

Catherine (Cait) M. DesRoches, DrPH, MSc, is Associate Professor of Medicine at Harvard Medical School and a health policy and data nerd with expertise in emerging trends in health care delivery.

Cait noticed early in her career that the concerns of patients and their families are often not the same as those of clinicians and policymakers.

Bringing this patient and family voice into the world of health services research led directly to her current role as the Director of OpenNotes.

She is the Principal Investigator of the OpenNotes Lab–which designs, evaluates, and guides innovations in clinical documentation, medical records, and patient engagement.