OpenNotes
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Introduction
Began as a national movement inviting patients to read their clinicians' notes online
A new U.S. law effective November 2020 requires rapid online access to clinical notes & other electronic record information for patients. These include:
- history & physical notes
- discharge summaries
- consultation notes
- progress notes
- procedure notes
- laboratory, imaging, & pathology report notes[4]
- psychiatry notes can be excluded
- vailability of retrospective notes is not required[4]
Clinical significance
- patients' review of notes may help them recall & understand their care plans
- may enhance safety through patient-reported documentation errors
References
- ↑ Bell SK, Gerard M, Fossa A A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships. BMJ Qual Saf. 2017 Apr;26(4):312-322. Epub 2016 Dec 13. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27965416
- ↑ Gerard M, Fossa A, Folcarelli PH, Walker J, Bell SK. What Patients Value About Reading Visit Notes: A Qualitative Inquiry of Patient Experiences With Their Health Information. J Med Internet Res. 2017 Jul 14;19(7):e237. PMID: https://www.ncbi.nlm.nih.gov/pubmed/28710055 Free PMC Article
- ↑ Bell SK, Folcarelli P, Fossa A, et al. Tackling ambulatory safety risks through patient engagement: what 10,000 patients and families say about safety-related knowledge, behaviors, and attitudes after reading visit notes. J Patient Saf. 2018 Apr 27 https://psnet.ahrq.gov/resources/resource/31749
- ↑ 4.0 4.1 4.2 Blease C et al. New US law mandates access to clinical notes: Implications for patients and clinicians. Ann Intern Med 2020 Oct 13; [e-pub] https://www.acpjournals.org/doi/10.7326/M20-5370