Medical Notes: Patient Access

Environmental & Science Education, STEM, Health, Medicine, Society

Ed Hessler

There is a provision in the 21st Century Cures Act requiring health care providers to provide electronic access to eight types of clinical notes. These are consultation notes, discharge summary notes, history & physical, imaging narratives, laboratory report narratives, pathology report narratives, procedure notes and progress notes. The rules do not apply to psychotherapy clinical notes. The Act is long and complex and I highlight an explainer for this specific provision from Open Notes.

Elizabeth Preston of STAT describes what she calls "a grand experiment in medical care." Her reporting includes information on characteristics of patients likely to be reading the notes, the problem of unpacking medical jargon, making notes more readable, adjustments doctors are making in their notes, e.g., from less critical and more supportive, and problems encountered with the rollout. 

Preston begins with a story about a patient who checked her notes and found some of the descriptions "disconcerting." This is one: "'She denies recent illness."' What this phrase means is standard medical terminology--jargon--that health care providers use to say the patient "had no recent illness that would have prevented her from getting that day's treatment."

These two may make you smile: "In some cases, clinicians' notes can seem offensive. 'F/U is used for followup, for example; 'SOB' stands for shortness of breath."

This "change may seem abrupt," but as Preston notes "researchers have been studying the impact of 'open notes' for years, including a pilot program launched by three medical groups about a decade ago." 

Consider two issues the author highlights in making the shift from a tool for health care providers to one that now includes the patient consider these two: "maintaining privacy for teens whose parents have access to their notes" and patients being able "to see test results immediately, rather than waiting to hear results from their doctors." These are not trivial.

Preston's reporting may be read here. It includes much more than I've discussed. And if you are interested in information about the 21st Century Cures Act as well as full access to it see here.