All of our doctors are taking notes during our visits. The thing is, their notes are often times your notes too. When our referrals are made to specialists, our doctors are sharing the notes for our medical visits. It is how providers can improve on continuity of care: that concerning conditions warranting referral are being followed up on and tracked.
Your providers’ notes contain a wealth of information and impressions that can be extremely helpful to us as well so we as consumers can stay on top of our own health. Reading our doctors’ notes can also help identify errors in the medical record and afford opportunities to correct the record. That in and of itself can help avoid devastating outcomes.
The Health Insurance Portability and Accountability Act, HIPAA, is federal law that allows you the patient to review all of your medical records. The Health Information Technology for Economic and Clinical Health Act (“HITECH”) is another federal law that lets you request and receive copies of your medical records in digital format for a minimal cost. To be clear, your visit notes and medical records consist of far more than after visit summaries we all receive.
As Kaiser Health News reports, accessing your own health care records can help reinforce concerns identified by your providers, and lead to an overall improvement in healthcare. As medicine continues to embrace the collaborative care model – the patient/provider shared decision-making model – this is seen as widely beneficial to the public. Our medical records have a lot of information that to a layperson may be hard to understand, but all of the terms are readily searchable online. Open Notes, a research project in Boston, is encouraging doctors sharing their notes and advocating for easier, more streamlined access around the country.
Educated patients can be more mindful during their visits and involved in the share decision-making process. This can help providers focus in on patient complaints for latent progressive issues. Doctors, after all, are busy people, and do not have the time to pour over our notes, lab results, test results, and referral notes. Time and time again we sit through depositions where providers explain they have the time to perform a cursory glance at these results, and unless something jumps out at them, do not have reason to take action.
One barrier millions of patients are having to overcome is the often convoluted, difficult process to request records from hospital systems. Washington’s law, for example, requires they provide records within fifteen days of a patient request, but gives little teeth to any enforcement process. The truth is some hospitals, clinics and providers are simply better than others at responding within the timeframe. It can be a frustrating process, but can help shed light on how your provider is addressing your complaints. From our perspective, while there is an aspect of “peering over your doctor’s shoulder” this effort for greater transparency has to no doubt lead to better patient outcomes as less missed diagnoses.
Read the Kaiser Health News article [here](https://khn.org/news/patients-should-read-doctors-notes-on-chart-to-improve-health/).
