Open Notes and Closed-Loop Communication: A Case of Factitious Disorder in the Age of Transparent Medical Records

A 31-year-old woman with a nursing background and loin pain-hematuria syndrome undergoes a renal autotransplant. During her recovery and prolonged hospitalization, her care team becomes increasingly concerned about a factitious disorder. With the roll-out of the 21st Century Cures Act Final Rule, which involves direct sharing of medical records with patients in real time, multiple inpatient care teams leave their clinical suspicion out of their progress notes for fear of damaging the therapeutic relationship. This case provides an opportunity to consider implications of the Final Rule policy of “open notes” for patients with sensitive psychiatric diagnoses, highlighting the need for effective communication and collaboration between inpatient teams and realistic approaches to the integration of documentation in patient care. Check for updates during her hospitalization. Factitious disorder is characterized by the falsification of symptoms for internal reward. Loin pain-hematuria syndrome is a rare condition characterized by chronic bilateral or unilateral flank pain and recurrent hematuria, hypothesized to have a psychogenic component [4]. While literature exists on the effects of the Open Notes Rule in the outpatient setting, little attention has been given to the changing dynamic in the inpatient care setting or to the effect on patient care when sensitive psychiatric information is relevant [5-7]. We will highlight the effects of Open Notes on team communication, treatment planning, and clinical outcome in this patient with factitious disorder, as well as potential strategies to address these unique dynamics.