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Posted By: Mary Knudtson, DNSc, NP, FAAN
April 27, 2021
The 21st Century Cures Act, passed by Congress in 2016, has gone into effect in April 2021. This gives patients the right to immediate electronic access to their health records—including not only test results, medication lists, and referral information, but also clinicians' notes. It requires that healthcare providers give patients access to all the health information in their electronic medical records without charge and "without delay."
The 8 types of clinical notes that must be shared are outlined in the United States Core Data for Interoperability (USCDI), and include: consultation notes, discharge summary notes, history & physical, imaging narratives, laboratory report narratives, pathology report narratives, procedure notes, and progress notes.
There are several types of clinical notes to which the rules do not apply:
- Psychotherapy notes that are separated from the rest of the individual's medical record
- Information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding
The Cures Act does not have a requirement for clinicians to change their note-writing style, though clinicians may want to consider adjustments when documenting sensitive topics such as mental health, substance use disorder, weight management and obesity, sexual history, and abuse. Tips for writing notes in an open-notes world include:
- Be honest: The note should be a true reflection of your communication with the patient during the visit.
- Minimize jargon and abbreviations: Remember your patients may not have a strong medical background and may easily misinterpret terms. Simplifying or defining terms (ie, using "shortness of breath" instead of "SOB," or writing "SOB [shortness of breath]") can go a long way to avoid misinterpretation.
- Be positive (where appropriate): It can be helpful and encouraging for patients to see their strengths and achievements highlighted. This can help them identify what they are doing well and reinforce which behaviors may need to change.
- Avoid potentially judgmental language: Instead of using labels such as "noncompliant," describe the behavior (ie, "Patient is not doing xxx"); instead of writing "poor historian," consider writing "patient could not recall."
In practices that have already implemented open notes, it has been found that sharing notes can improve communication among patients, families, and clinicians—often building a stronger, more trusting relationship and enhancing patient safety. Open notes also have been shown to improve adherence to medications. As the open-note practice encourages transparency and inclusivity, it can help turn passive patients into active safety partners. Further, the use of open and honest communication may help decrease legal action against medical malpractice.
- American Academy of Family Physicians. Patients will soon have expanded rights to read your clinical notes: How to make them patient friendly. www.aafp.org/journals/fpm/blogs/inpractice/entry/open_notes.html. Accessed April 20, 2021.
- OpenNotes. OpenNotes for health professionals. www.opennotes.org/opennotes-for-health-professionals/. Accessed April 20, 2021.