News: Patients will soon have access to clinical notes

CDI Strategies - Volume 14, Issue 49

By Monday, November 2, all patients will have immediate access to clinical notes, test results, and imaging. That’s the date that the 21st Century Cures Act, set for compliance with a new rule granting such access to electronic health record items such as consultations, discharge summaries, history notes, physical exam findings, imaging narratives, laboratory and pathology report narratives, and procedure and progress notes.

The 21st Century Cures Act states that “the implementation of these provisions will advance interoperability and support the access, exchange, and use of electronic health information.” Giving patients immediate access to clinical notes could be potentially confusing and alarming for patients, leaving them frightened or annoyed by notes containing sensitive information. There is also concern that the Act will cause increased workload for providers as they tailor notes for patients and answer questions.

Conversely, patient access to clinical notes can also lead to better doctor-patient communication, as well as allowing patients to play a more active and aware role in their health. Such transparency may very well be yet another reason for CDI expansion in to outpatient and specialty office settings to help physicians get the clearest, most accurate information into the medical record the first time, every time.

Editor’s note: The 21st Century Cures Act can be found here. For more information about patient access of medical records, click here. To read about a study that found 20% of patients identify errors in their own records, click here.

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