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JAMA Patient Page
November 2, 2021

What to Consider When Reading Your Medical Notes

Author Affiliations
  • 1Associate Editor, JAMA
JAMA. 2021;326(17):1756. doi:10.1001/jama.2021.16493

Shared medical visit notes are notes written by clinicians that are made available (“open”) to patients in electronic health records.

Clinicians add medical notes to a patient’s electronic health record following clinical encounters such as office visits. There is no difference between the notes that patients can view and those that clinicians keep on file.

In 2021, new legislation was introduced in the US that required almost all medical notes to be shared with patients. These notes include

  • History and physical notes

  • Progress notes

  • Consultation notes

  • Procedure notes

  • Discharge summary notes

  • Imaging narratives

  • Laboratory report narratives

  • Pathology report narratives

There are a few exceptions. Some medical notes that do not need to be shared with patients include psychotherapy notes that are separated from the rest of the medical record, written by any health care professional; information related to a civil, criminal, or administrative action or proceeding; and any note that a doctor perceives may cause harm or danger to a patient.

The goal of note sharing is to increase transparency between clinicians and patients. Some studies have shown that shared medical notes may help patients feel more engaged in their health care, better understand their medical conditions and care plans, and take their medications properly.

Approach to Reading Medical Notes

Patients are typically able to access their notes through a patient portal to their electronic health record. The notes are there for a patient’s consideration and are optional, not required, reading. The main purpose of medical notes is to communicate information among health care professionals, not between doctors and patients. A patient can avoid reading their medical notes if they find that the information causes them too much worry.

When patients do choose to read their medical notes, it is important to approach them in the right way—not as a clinician, but as a patient. You can discuss with your doctors whether or not you plan to read your notes, which may help them put more patient-directed information (such as follow-up instructions) directly in the notes. If you identify anything in your note that concerns you, discuss that information with someone on your health care team.

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The JAMA Patient Page is a public service of JAMA. The information and recommendations appearing on this page are appropriate in most instances, but they are not a substitute for medical diagnosis. For specific information concerning your personal medical condition, JAMA suggests that you consult your physician. This page may be photocopied noncommercially by physicians and other health care professionals to share with patients. To purchase bulk reprints, email reprints@jamanetwork.com.
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Article Information

Conflict of Interest Disclosures: None reported.

Source: Delbanco T, Wachenheim D. Open Notes: new federal rules promoting open and transparent communication. Jt Comm J Qual Patient Saf. 2021;47(4):207-209. doi:10.1016/j.jcjq.2021.02.004