What information is there about me in my medical record? There’s certainly diagnosis, medications, procedures, allergies, treatment plans, referrals, diagnostic test reports (labs, radiology, EKG, pathology). I have more access to that information these days through visit summaries given at the end of the visit and on the different portals my providers have. But what about the notes they write? What is in those notes? How the plan /medications are working, my mood, concerns about my safety or my ability to think clearly, questions I ask with the answers given, calls the clinician makes about me, calls they receive about me, their thought process as they manage my care. I can legally obtain these notes now by asking for a copy of my full medical record, but its cumbersome, complicated, costs money, and very, very seldom done. The movement to give us access to these clinician notes through a patient portal is called, Open Notes. (for more information click here) The VA and several hospital and physician clinic systems have committed to Open Notes. A study in the Annals of Internal Medicine (click here) was done that found Patients accessed visit notes frequently, a large majority reported clinically relevant benefits and minimal concerns, and virtually all patients wanted the practice to continue. With doctors experiencing no more than a modest effect on their work lives, open notes seem worthy of widespread adoption.
I receive some of my care at one of the Open Notes pioneering institutions, but I see no notes on my Patient Portal. I will ask next week when I see the specialist. I completely support the Open Notes initiative. I want access to anything about me. I do have some thoughts and questions though:
- As a clinician myself, having read tens of thousands of notes, it’s hard work finding relevant information in those notes. Clinicians don’t all write in an informative manner. Abbreviations abound. It will be interesting to see how note writing evolves as Open Notes proliferate.
- Can I challenge an error? This is no different than errors in my medication lists or vaccinations. I have tried to correct something in my record with no affect. This will continue to be a challenge.
- Will clinicians continue to write about concerns with my safety and state of mind? Read more about this here.
Have you experienced Open Notes? What do you think about access to Open Notes?
