MEDICAL RECORDS

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Traditionally, doctors have kept medical records on patients as a means of tracking the patient’s health over time and as a memory aide for the doctor. The notes were handwritten and often illegible, sometimes even illegible to the person that wrote them. With technological improvements in this digital world, except for a few small offices, medical records are now kept in electronic form.

Preparing and keeping electronic medical records demands much more time from the clinician as opposed to what handwritten notes used to require, however electronic records tend to be much more complex and comprehensive. Still, electronic medical records contain abbreviations, symbols, and other jargon that lay people would not be familiar with. One of the main advantages of electronic records is that they can be shared with other practitioners and specialists caring for the patient, thereby facilitating the flow of information among the clinicians caring for the patient.

Medical records were never designed to be shared with patients, however, considering that legally the records are the property of the patient, not the doctor, many offices and health systems have created patient portals. These portals allow the patient to directly read and review their own medical records. In 2021, new legislation was introduced in the U.S. that required almost all notes to be shared with patients. The notes required to be shared include history and physicals, progress notes, consultations, procedure notes, discharge summaries, imaging narratives, laboratory reports, and pathology reports. The goal of record sharing is to increase transparency between clinicians and patients. Some studies have shown that record sharing allows patients to feel more engaged in their health care, better understand their medical conditions and care plans, and improve the ability of patients to take their medications properly.

Of course, information available to the patient via a portal is optional, not required, reading. Remember that the main purpose of medical notes is to facilitate communication among health care providers, not between doctors and patients. If you plan to read your notes, let the doctor know so that more patient-directed information can be placed in the notes (i.e., follow-up instruction). Remember to read the records as a patient, not as a clinician. If you identify anything that concerns you, discuss it with someone on your health care team.

If you plan to read your notes, here are a few suggestions: review the care plan for any new medications or orders by the doctor. Use this to make a “to-do” list for yourself prior to your next visit; wait for your doctor to contact you regarding any lab results, imaging studies, or other reports. These may be placed in the file electronically before the doctor has reviewed them; review your medication list for accuracy; let your healthcare team know about any major errors or missing information (like allergies); share your notes with people close to you who are involved in your medical care.

Here are a few don’ts: don’t get caught up in medical jargon or terminology; don’t take any language personally; do not attempt to interpret anything without first talking to your doctor.

For more information go to: www.healthit.gov/curesrule/   or www.opennotes.org/ 

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 By Peter Galvin, MG

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