OpenNotes

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Open Notes is a national initiative that allows or rather encourages patients access to access their Personal Health Record. [1] Open Notes gives patients’ access to the appointment (visit) notes written by their doctors, nurses or other clinicians. Up until now clinician notes have remained largely hidden from patients. [2] Open Notes fueled by the Robert Wood Johnson Foundation and 2 hospitals and Geisinger Health System took park in allowing 20,000 patients access to their primary care doctors notes.

Introduction

With health care and technology merging more every day evidence shows the benefits of having patients more involved with their care and health care team is improving outcomes.

Opening up visit notes is showing to:

  • Improve communication
  • make care more efficient
  • may help patients become more actively involved with their health and health care
  • build better relationships with provider and patient

Open Notes read by patient’s shows:

  • patients better remember what is discussed during the visit
  • Feel more in control of their care
  • Are more likely to take medication as prescribed
  • increase continuity with care plans

Open Notes does come with options for clinicians. The clinician always has the option to use a "HIDE NOTE" option. Not all visits will be made available for patients to read notes. Examples of visits could vary by institution: mental health, addiction medicine, occupational medicine, pain clinic, employee health and adolescents between 13 and 17.

Open Notes may not be available for inpatient stays, nurse visits or Emergency Department visits.

If a patient disagrees with a note patients may request corrections or changes usually through a release of medical information services department.

References

  1. Open Notes http://www.myopennotes.org/
  2. The Road Toward Fully Transparent Medical Records. Jan Walker, RN, MBA, Jonathan D. Darer, MD.,MPH., Joann G. Elmore, MD., MPH., and Tom Delbanco, MD. N Engl J Med 2014; 370:6-8 http://www.ncbi.nlm.nih.gov/pubmed/24304001