Why is it necessary to include a note in the patients chart when the person does not show up?

Whether you’re learning about open notes and how notes can help you, getting ready to start reading notes, or are an experienced user of notes, here are some answers to questions people often ask:

After office or tele-visits, doctors, nurses and other health care providers write notes that summarize important information about you. These notes become a part of your medical record. And when a note is shared with you, it becomes an "open note." It may include:

• A summary of what you told the doctor or nurse, also called a “history.”
• The provider’s findings from a physical exam. Examples might include blood pressure and weight, how your lungs or heart sound, a description of a growth on your skin, or observations about your mood.
• Your provider’s thoughts about results of your lab tests, x-rays, scans, biopsies, or other studies.
• Summary thoughts about any medical conditions or symptoms, also called “assessment” or “impressions.”
• Recommendations made during the visit, often called the “treatment plan,” or “plan of care.” The notes might include tests, follow up appointments, referrals, exercises, or changes in your diet

How notes look depends on many things: who writes the note, the kind of visit, where you get care, etc. Sometimes the notes are short. Others include a complete description of the visit and may also include additional details about your health, such as past problems or test results. And due to various rules and regulations, some may include information that doesn’t seem very relevant.

• Research shows that most people remember less than half of what they discuss with their medical professionals during a visit. To make sure you don’t miss important information, open notes give you the opportunity to review the details of your visit at any time.
  • Many studies now show that reading open notes can help people manage their health care in a way that makes them feel more confident, prepared, and in control.
  • Open notes can clarify what you’re supposed to do between visits, help you understand your medications, and remind you to schedule follow up appointments and preventive tests, such as mammograms or eye exams.
  • People who have their notes available report sharing their medical information more effectively with family members, other care partners, or health professionals beyond their regular health care team…but only if and when they wish.
  • Many people are involved in medical issues with their parents, children or others. Do you rely on assistance for your own care? Sharing notes makes partnering easier.
  • Information is power. Finding medical information easily helps people ask better questions and make more confident decisions. Research shows that seeing what doctors, nurses, or other clinicians write often builds trust between people and their health care team.
  • More than 9 of 10 people report understanding their notes, even though at times they may need to turn to the Internet or ask someone for help.
  • Studies show also that people can identify mistakes and help make sure their records are accurate.

• • Read your notes after a visit. Very often the notes will contain things you forgot. They may remind you about important plans, ranging from medications to tests, or simply what you and your provider agreed on for next steps.
  • If there are terms you don’t understand, you might try to look them up, or ask your provider for reliable websites or other resources that will help you learn more. A good resource to start with is the list of Common Abbreviations on MedlinePlus.
  • Review your note to make sure the information is accurate and up to date. Let your healthcare team know if there’s a problem you feel is important.
  • If your notes have medications listed, check to make sure what you are taking matches: your name, how much you take, and how often.
  • Read your notes again between visits, especially if you need to remind yourself about the treatment plan, upcoming procedures, tests, or appointments.
  • Use your note to make a “to do” list for yourself. You may want to bring it to your next visit.
  • You might share your note with family, care partners, or others involved in your care. It’s important to have your entire care team on the same page, and sharing can help with both health and illness.
  • Before your next visit, read your note to remind yourself about your last conversation with your doctor or nurse. Think about two things: a) What has happened since you last saw your doctor, and b) What are your two or three most important goals or questions for the visit?

• • Does it describe the visit accurately? Did you and your provider leave the appointment on the same page?
  • Should you share the note with another member of your care team or family?
  • Is there anything you’re worried about that needs follow up?
  • Is there anything you don’t understand? Could you use some help with medical terms, a diagnosis, or the care plan?
  • Is there information, such as symptoms or important family history, you forgot to share at your appointment?
  • Are there inaccuracies in your record that need follow up?

Your note may have medical language that’s not easy to understand. You can find a lot on the Internet, but try to make sure it comes from a reliable source. View this list of common abbreviations to help you with medical terms. If you have questions, write them down. Follow through, whether with a friend, your doctor, or any source you trust.

Note reading may not be right for everyone. Follow your instincts. For some people, just knowing that the notes are available is enough. Thousands of patients report that the benefits from reading notes are much greater than the risks. In fact, reading notes often builds or reinforces your trust in those taking care of you. And studies show that very few people report feeling harmed by what they read.

By federal law, you have the legal right to receive and review all of your medical records, including the notes. Starting April 5, 2021, most providers are required by law to make them available by electronic means, such as through secure Internet patient portals. There are a few exceptions, but the vast majority of notes should be available, no matter what health condition you may have.

If your notes are not yet online or you don't have a way to use electronic communications, you can always ask for a paper copy.

If you still have trouble, visit whereismymedicalrecord.org, a collaboration between OpenNotes and Ciitizen.

Possible reasons include:

• You may need help finding the note within your electronic record. Unfortunately, that’s not always easy.
• The note may not be ready. In some practices, notes are available quickly. In others, it may take several days for them to appear in your record.
• The doctor, nurse or other health care provider may not yet be sharing notes.
• The note may have been written before your health system began sharing notes.
• Your doctor, nurse or therapist may have chosen not to share this particular note. We encourage you to talk with them about this. It’s best to be on the same page.
• If you still have trouble, visit whereismymedicalrecord.org, a collaboration between OpenNotes and Ciitizen.

If it’s serious—something that could affect your care urgently—contact the office of the health care provider who wrote the note.

For other mistakes or inaccuracies, bring them to your medical team’s attention, particularly if you think correcting the note will affect your current or future care. Your healthcare provider’s office will have a process for helping ensure accuracy.

It’s important to know that open notes do not change the entirely confidential relationship you have with your health care providers. They can share your information only with health professionals who care for you and with some administrative personnel who also have the legal and ethical right to see your personal health information.

On the other hand, the information in your records is about you, and you can choose to share it with others. With ready access to your notes, it’s much easier to share your medical information with a care partner, family member, or others—but only if you choose.

To help ensure your privacy when using an online patient portal, remember to:

• Keep your login name and password private
• Always exit the website by selecting “sign out” or “log out” when you are done

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 utilize notes to partner with patients and care partners efficiently and actively, and they study what happens as a result.

Learn more about OpenNotes