After an office visit, doctors, nurses, and other healthcare providers write notes that summarize important information about you. These notes become a part of your medical record.
Did you know?
- Health systems are required to share your notes with you
- Reading your notes can help you manage your healthcare
- Reading your notes can help you take more control of your health
- Studies show that open communication with your doctor or nurse benefits you and your care partners
After a medical visit, doctors, nurses, and other healthcare providers write notes that summarize important information about you. These notes become a part of your medical record. When a note is shared with you, it becomes an “open note.”
An open note may include:
- A summary of what you told the doctor or nurse, also called a “history.”
- The provider’s findings from a physical exam. Examples may include blood pressure, weight, how your lungs or heart sound, a description of a growth on your skin, or observations about your mood.
- Your provider’s thoughts about the results of your lab tests, x-rays, scans, biopsies, or other tests.
- Summary thoughts about any medical conditions or symptoms. This section may also be called “assessment” or “impressions.”
- Recommendations were made during the visit. This section is often called the “treatment plan” or “plan of care.” Notes might include ordered tests, prescribed medications, follow-up appointments, referrals, exercises, or recommended changes to your diet.
How notes look depends on many things, including who wrote the note, the kind of visit you had, or where you get care. Some notes are short. Others might include a complete description of your visit. Longer notes may include additional details about your health, such as past problems or test results. Some notes may include information that doesn’t seem relevant due to various insurance requirements or other rules and regulations.
Research shows that most people remember less than half of what they talk about with their doctor. An open note helps you remember important information. It also gives you freedom to review details of your visit at any time.
Studies show that reading open notes can help you:
Manage your health care in a way that makes you feel more confident, prepared, and in control
Better understand your medications and what you need to do between visits
Remember to schedule follow-up appointments and tests, such as mammograms or eye exams
Do you rely on help for your own care? Sharing notes makes partnering easier. Many adults help parents, children, and others facing medical issues. People who read their notes say the notes make it easier to share health information with family members and others.
Information is power. More than 9 out of 10 people report understanding their notes. Open notes also build trust between patients and their healthcare team.
Having access to and looking at your medical information helps you ask better questions. Research also shows that people who read notes can identify mistakes in their records and help make sure the records are accurate. How To Use Open Notes – Your Guide to the World of Open Notes
Read your notes after a visit and refer to them in between visits. Often, the notes contain things you forget. They may remind you about important plans, medications, tests, or other next steps. When you review your note, make sure the information is accurate and up to date. Let your healthcare team know if there’s a problem you feel is important. Check to make sure the medications you are taking are named correctly in your notes. And make sure the medications match your name and describe how much you take and how often.
Read your notes between visits if you need to remind yourself about your treatment plan. Reading your notes can remind you of upcoming procedures, tests, and appointments.
Use your note to make a “to do” list for yourself. Bring it to your next visit.
You might share your note with family, care partners, or others involved in your care. It’s important to have your entire care team on the same page.
Before your next visit, read your note to remind yourself about your last conversation with your doctor or nurse. Ask yourself, “What has happened since I last saw my doctor? What are my two or three most important goals or questions for this visit?”
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