Survey of sensitive information written in patient notes by psychiatry trainees

Objective: Allowing psychiatric patients access to their electronic medical record (EMR) may cause difficulty related to the sensitivity of the note content. The authors investigated whether notes written by psychiatry trainees were ready for release to patients. Methods: Authors conducted a review of 128 PGY-3 to PGY-5 outpatient notes not explicitly marked as "highly confidential." One psychiatrist and one non-psychiatrist read each note from the patient's perspective. Reviewers assigned a score of 0-2 (0: No Concern; 1: Some Concern; 2: Major Concern) for each note. Results: Eighty-nine notes (70%) were assessed as "No Concern" by both reviewers; 30 (23%) were of "Some Concern;" and 9 (7%) were of "MajorConcern;" 92 (72%)were deemed of "NoConcern" by a psychiatrist, as compared with 120 (94%) by the non-psychiatrist. Conclusions: Trainee EMR outpatient notes are not likely to cause major concerns for patients who read them. Psychiatristreviewers identified more concerns than non-psychiatrist-reviewers.