Patients have a legal right to obtain copies of their medical records. [FOR THE RECORD: 12:25 p.m: An earlier version of this post said patient records belong to the patient. Under most state laws, they belong to a doctor or healthcare group. However, patients have a legal right to obtain copies of their records.] Patient records, however, are meant to help the doctor or other health professional organization obtain information and treat the patient safely and effectively.
So what would happen if patients had much easier access to the doctors’ notes? The answer to that question should become clear later this year. Researchers led by a team at Beth Israel Deaconess Medical Center in Massachusetts have launched a pilot program called the OpenNotes Initiative. The program will allow about 25,000 patients in Massachusetts, Pennsylvania and Washington to read their doctors’ notes on a secure Internet portal. The patients and doctors will then fill out questionnaires about whether the project helped or hurt.
Some experts say allowing patients to read the doctors’ notes will help them better understand their condition and improve communication and shared decision-making between the doctor and patient. But others worry that the notes — really meant for the doctors’ eyes only — may confuse or upset patients.
If doctors know their patients are reading the notes, will they write as candidly as they might otherwise? After all, doctors and nurses use their notes to remind themselves about a patient’s unique characteristics and medical histories. This can mean something like, “Mr. Smith is typically in a foul mood and is convinced he’s going to die.” Or, “The parents of the Smith baby seem exhausted and are worried about their ability to care for the baby at home.”
“Opening documents that are often both highly personal and highly technical is anything but simple; the implications are broad and filled with uncertainty,” the authors wrote in an article on the project published Monday in the Annals of Internal Medicine. Further, they add: “Doctors’ notes can also stifle or fuel the fires of litigators.”
I love to read doctors’ notes from my own chart or a family member’s (if they permit me to do so). Sometimes reading the notes gives me a glimpse of how the doctor feels about the case and increases my appreciation — wow, he really does care — or what kind of concerns exist that I was unaware of. Nurses too often provide detailed observations that can help people understand what’s going on.
For more information on OpenNotes, go to https://www.annals.org.
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