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GPs urged to use 'patient-friendly language' in records

GPs may need to omit important clinical information and switch to using lay language in patient notes if the Government presses ahead with plans to give patients online access to their records, medical defence experts are warning.

Patients notes could become less useful as doctors feel the need to leave out information – such as differential diagnoses – that might distress patients, the Medical Protection Society said.

The MPS also warned of the potential for GP workload to increase and for ‘enormous strain' on the doctor-patient relationship in its response to the Department of Health's consultation on plans to give patients online access to their health records by 2015.

‘It will be a big cultural change for clinicians to use patient-appropriate language,' said the MPS's formal consultation response. ‘Clinicians will have to consider the need to inform and reassure patients [to avoid] an increase in consultations to explain records to worried patients.'

It called for a category of sensitive information, that would be protected from online viewing, ‘for example, where there are issues in mental health, sexual health, child protection and counselling'.

The MPS said it supported the principle of giving patients greater access to their health information– but warned there was a risk of unrealistic expectations.

‘Greater online access to health professionals comes with consequences, such as use of clinician time,' the response said. ‘The aspiration that patients will be able to contact their health team electronically for "routine support" may lead patients to expect their emails will be answered straight away.'

Dr Stephanie Bown, director of policy and communications at the MPS, said it was vital to preserve the primary purpose of medical records – communication between health professionals to ensure high-quality care.

She said: ‘Greater patient access to records may impact on the content of records, with the need for doctors to use patient-friendly language and consider omitting entries that may cause distress.'

Dr John Etherton, a GP in Rottingdean, east Sussex, said the changes could be ‘a nightmare'.

He said: ‘Clinicians are trained to use our own short, quick and highly professional language. Putting it into layman's terms will mean a duality of entry that will increase our workload.'

He added: ‘The records were never designed for consumption by the patient.We can't omit differential diagnoses. We'll be treading on thin ice.'

 

Story updated: 10:44 07/09/12

 

The Government's proposals

-  Practices to appoint lead GP to organise direct access to records to any patient requesting it

-  GPs must arrange online appointment booking and a secure email system for patients to contact their practice by 2015

-  Repeat prescriptions and test results to be accessible online

Source: 'Power of Information' – Department of Health

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Readers' comments (1)

  • I really think that doctors are under estimating patients . Patients have been learning to gen themselves up for a long-time since the internet. It makes sense to ensure that the record is one that is mutually accessible as patients these days expect to quite rightly have control over their medical health. What is the point of having info that in inaccessible? If docs have a differential diagnosis then it needs to be recorded as such so the patient knows!

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