Open Notes - Good News About Your Medical Records

Do you know what is in your medical records?

You have probably been told that it is important to get and review a copy of your medical records.  Up until now, it’s been expensive and often challenging to get them. 

For those of us in the US, a big change happened in April 2021, that gives patients online access, without delay, to the medical notes in our medical records. 

Federal Rules Mandating Open Notes

Beginning April 5, 2021, the program rule on Interoperability, Information Blocking, and ONC Health IT Certification, which implements the 21st Century Cures Act, requires that healthcare providers give patients access without charge to all the health information in their electronic medical records “without delay.”

https://www.opennotes.org/onc-federal-rule/ 

What are medical notes?

Medical notes are written by the medical providers as a way to document the appointment and as a communication tool with other providers. 

In the past, they were only accessible to patients who requested a copy of all of their medical records so seldom read by most patients.  

As it was a communication tool between providers, they often contained abbreviations and were written in short-hand format. 

Billing codes and data to support them can influence the notes because certain phrases (ROS - review of systems) allow for higher billing or more billing codes.  

But, as many rare disease patients found out, incorrect or incomplete information written in our medical notes can adversely affect our ability to get appropriate care in the future.

What notes are included in the Open Notes mandate?

The eight (8) types of clinical notes that must be shared are outlined in the United States Core Data for Interoperability (USCDI) and include:

• consultation notes
• discharge summary notes
• history & physical
• imaging narratives
• laboratory report narratives
• pathology report narratives
• procedure notes
• progress notes

Clinical notes to which the rules do not apply:

1. Psychotherapy notes that are separated from the rest of the individual’s medical record and are recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session. Note: All clinicians and organizations are required to share medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
   
   
2. Information compiled in reasonable anticipation of, or use in a civil, criminal, or administrative action or proceeding.

What does this mean for you?

What this means for you is that as of April 5th moving forward, the notes from your appointments, consults, testing, imaging, pathology, discharge and summary notes, procedure notes, and progress notes will be accessible to you through the patient portal - automatically and without delay!

Lab and imaging reports that used to be released only to the doctor will now be accessible and included in your online medical record. 

Notes written to your PCP from a specialist will be directly available to you.

ER, and Hospital discharge notes will be part of your medical record. 

You will be able to see the medical notes, review them, and ask for revisions if/when necessary.

Open Notes is a huge step forward in transparency and including the patient as an engaged partner in their healthcare!

What to do if your notes aren’t released

People who are unable to access their personal health information for clinic visit dates on or after April 5, 2021, and who are not being provided with this information “without delay” from their clinicians or health systems, are able to submit a report of “information blocking” through the U.S. Department Health & Human Services website.

You can submit an information blocking report by visiting the HealthIT.gov Help Center and clicking the link to “Click here to raise a request without an account.” OpenNotes encourages you to read the details under the “Additional Considerations” section.

Kudos and a big thank you to the OpenNotes project

OpenNotes is a not-for-profit international movement started in 2009 by health professionals at Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, Massachusetts. It is supported entirely by grants from private foundations, gifts from donors, and federal research grants. OpenNotes does not develop or sell software or commercial products. Its staff includes doctors, nurses, mental health professionals, social scientists, and patients and their care partners. Those working with OpenNotes have two principal activities: They urge health care providers and systems to share notes with patients and care partners efficiently and actively, and they study what happens as a result.

Check out your online medical records and let me know if you can now see your medical notes.

Note:  This content from “Federal Rules Mandating Open Notes” by OpenNotes, is available under a Creative Commons Attribution 4.0 International license.