What Is Open Notes?

Open Notes (or the Open Notes Movement) is a National initiative that encourages physicians to allow patients to see the progress notes that get entered into an electronic health records (EHR) system during medical visits. Traditionally, this part of the medical record has not been released to patients unless they specifically asked for it from the physician office or a hospital’s Health Information Management (HIM) department. The mechanism by which notes are made available to patients is usually through web-based patient portals. Test results have typically been released to patients via patient portals for many years now.

The official governing and proponent organization for the Open Notes movement is OpenNotes.org. Their studies suggest that opening progress notes to patients could make patient care more efficient, improve communication, and help patients to be more engaged in their care. They also report that when the program is piloted at a given organization, both patients and providers opt to continue the effort after the trial period.

Opponents of Open Notes have concerns that just the presence of notes being released may influence what the physicians put into the notes in the first place, and that exposing patients to medical terminology results in confusion and fear on the part of patients. There is also the ever-present fear of legal action, although that isn’t as prevalent as a lot of people assume.

Even in the most liberal open notes environments, there are still exceptions to what gets released to patients.  Behavioral health notes and notes that may have sensitive information such as domestic abuse history typically will not be released.

Organizations Using Open Notes

This graphic from OpenNotes.org shows that over 7 million patients now have access to progress notes from their physicians. Some of the largest groups who are using open notes are MD Anderson, parts of the Kaiser organization, and the VA.

organizations-using-open-notes

 

 

 

 

 

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What Is Open Notes
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What Is Open Notes? Learn about this initiative to allow patients to have access to physician notes in EHR systems, and why it matters.
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HealthcareITSkills.com
HealthcareITSkills.com
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