Seeing Your Doctors Notes About You

SEEING YOUR DOCTORS NOTES For 40 years, the tension over patient access has been playing out in hospitals, clinics and doctors offices. Although medical records have always been accessible to clinicians, payers, auditors and even researchers, it was not until the 1970s that a few states began giving patients the same rights.

The PCPs with whom we spoke seemed to worry first and foremost about the effect on their time, that is, they anticipated calls, letters, and e-mails as patients seek clarification; disagree with statements; or correct what the doctors consider trivial errors of fact. Our doctors worried further about inappropriate reactions to what patients read.

Patients also voiced pros and cons. Some clearly did not want to read what their doctors wrote because they were worried about discovering something they would rather not know, finding potential diagnoses that might make them anxious, or reading what their doctors really thought of them. 

These can be real world concerns and may have damaging effects on the doctors’ relationship with the patient. Knowing that the patient may be reading these note might cause the doctor to be more sterile in their writing, perhaps losing what could be telling and useful descriptors that aid in knowing the patients history.

Hopefully these notes are entered into an electronic format. We have heard that doctors handwritten note of old were often chicken scratch and very difficult to read.

Should Patients Read the Doctor’s Notes? Pauline W. Chen, New York Times

Open Notes: Doctors and Patients Signing On, Tom Delbanco, MD, Jan Walker, RN, MBAJonathan D. Darer, MD, MPH, Annals of Internal Medicine, American College of Physicians.