a doctor on a computer, medical records, electronic medical records, interns, visit notes

Many if not most health systems and doctors’ offices around the country have adopted electronic medical records. As a result, patients can access appointment information, pay their bills, check their lab results and in a few cases read the visit notes that detail their clinical condition.

What Are OpenNotes?

The idea of OpenNotes originated at Beth Israel Deaconess Medical Center in Boston several years ago. The inventors wanted to make the doctor’s insights available to the patient. Other health care providers considered this a radical undertaking at the time. Now, however, OpenNotes has become an international movement. It urges doctors, nurses, therapists and other health care providers to share the notes they write describing patient visits. Such visit notes are standard; OpenNotes are different because patients get to read them.

Not all health care systems offer patients access to the doctors’ clinical notes. Those who do, however, have found it helpful. Doctors were initially skeptical of this idea, but those who have tried it often find it useful. Three large health care systems that have embraced the practice are Beth Israel Deaconess Medical Center and its affiliates in Massachusetts, Geisinger in rural Pennsylvania and the University of Washington Medicine is Seattle, Washington.

Do Patients Benefit from Reading Their Visit Notes?

New research supports the value of OpenNotes (Journal of Medical Internet Research, May 6, 2019). Investigators surveyed nearly 30,000 patients who had used the patient portal in one of the three health systems mentioned. They had conducted the initial research seven years previously. Ninety-eight percent of the respondents agreed that online access to visit notes was helpful. Seventy-three percent said that reading the notes helped them take better care of their health, while 66 percent reported that these notes reminded them of the plan of care. This may permit patients to follow through better toward achieving their health goals. 

Although doctors sometimes object that patients will be confused or anxious if they are allowed to read their visit notes, the researchers report this rarely happened. About 3 percent of patients said they were confused by what they read. Fewer than 5 percent were more worried about their health conditions after reading the visit notes than they had been before.

The authors note:

“Less educated, nonwhite, older, and Hispanic patients, and individuals who usually did not speak English at home, were those most likely to report major benefits from note reading.”  

In particular, they conclude:

“…OpenNotes brings benefits to patients that largely outweigh the risks.”

Previous studies have shown that visit notes are not always accurate. If you have access through your own patient portal, you should check the information so you can request corrections if necessary.

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  1. Mark Smith

    Thanks for sharing peoples pharmacy and appreciate for article.

  2. Audrey
    Salt Lake City, UT

    I have stopped reading my notes. Innocently named “My Chart”, the notes are really “Their Chart”. I have not been able to correct inaccuracies, errors, or update medications. We waste time every visit going over the medication chart, which I have not been allowed to update, and which the technician is also unable to update, because they are wrong again at the next visit. Until this process becomes meaningful, it is not being done for my benefit.

  3. Kara

    I always ask for a copy of the doctors’ notes. And there is almost always at least one major error. My left broken foot was written as my right foot. My injury from tripping over a curb was described as a “basketball injury”. The doctors often send their notes to be transcribed by people who don’t know you and use boilerplate information that is often meaningless to your situation.

  4. rickee

    Please DO take the time to read the clinic notes you receive from your doctor’s office. I was preparing for surgery and met with a physician’s assistant for some history and preliminary testing. When I received the notes, I was truly alarmed. The report was at least 95% inaccurate with some very serious discrepancies, including a test I had not even been given and its results. These notes were being forwarded to my surgeon. I immediately sent back a response, addressing each point with the correct information. The PA called me and admitted she had accidently put another patient’s information into my record. If I had not taken the time to read these clinic notes, some harmful and potentially dangerous medical information would have reached my surgeon and could, possibly, have had an impact on my surgery.

  5. Sherry
    Redmond, WA

    Unqualified *YES*! A few years back, before eCharts, I saw my notes from a visit with a primary care doc that I was considering switching to and I was wondering who the patient was. She had so many things totally wrong about my medical history!

    I wrote a 2-page letter to the doctor and cc’d the clinic director and medical director, clarifying the issues. Can you believe, I *never* heard back from any of them? Needless to say that was my last visit to that clinic.

    Unless you have an understanding of medical terminology and health issues, it could confuse you and cause undue concern. I’ll never forget the patient who was reviewing his records (I worked in Medical Records at the time) and got really angry when he read “The patient came in SOB” not realizing that SOB mean “short of breath” and thought the doc was calling him a not nice name!

  6. BJ

    I love using the patient portal in communicating with my doctor! His nurse also has access to my e-mails and is prompt in replying,
    So much time is saved on my end and also in doctor’s office.
    Positive improvement in health care.

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