Health care patients in the U.S. can now immediately access physician clinical notes, test results, and reports under a newly enacted federal law.
The new law (known as “open notes”) was passed as part of the 21st Century Cures Act. It took effect on April 5, 2021 after the initial effective date was pushed back due to the pandemic.
Under the open notes mandate, health care organizations must provide patients with free, full, and immediate electronic access to medical notes and related records via patient portals. Providers and organizations that fail to comply with the new mandate will eventually be subject to fines from the HHS for information blocking.
The eight types of clinical notes that must be shared under the mandate include notes related to:
- Consultations
- Discharge summaries
- Medical history and physical examination
- Imaging narratives
- Laboratory report narratives
- Pathology report narratives
- Procedure notes
- Progress notes
As open notes become a reality in U.S. health care, here are a few important things to know:
Writing Styles May Become More Patient Friendly
The new law mandates only timely access to patient notes / reports and does not require providers to change how they write medical notes. However, because patients are now part of the audience, many health care systems and clinicians are shifting toward a more patient-friendly style.
According to experts, increasing access to clearly written medical notes can allow patients to play an active role in their health care and treatment plans. Purported benefits include improved accuracy of medical records, greater medication adherence, and the potential for improving health care disparities across patient types.
Some Notes May Be Withheld
Not all medical notes are subject to the new mandate. This includes psychotherapy notes that are separate from the rest of an individual’s medical record and information compiled for use in civil, criminal, or administrative proceedings.
Additionally, the open notes mandate allows providers to withhold information if there is evidence that doing so “will substantially reduce the risk of harm” to patients or other third parties. Some state laws may also restrict access to certain notes. In California, for example, state law prohibits providers from posting cancer test result without first talking to patients.
Open Notes is New Law But Not a New Concept
With the adoption of the open notes mandate, the U.S. joins Scandinavian countries in leading a new global movement intended to ensure transparency in health care.
And while the U.S. is a frontrunner in this respect, open notes are not entirely a novel concept. Prior to the nationwide mandate kicking in on April 5, there were over 200 medical organizations across the country that voluntarily provided open notes through online platforms. These providers have demonstrated that open notes can work to the benefit of patients.
Exercise Your Right to Access Medical Notes
As a firm that fights for victims injured by negligence, our team at Levinson Axelrod, P.A. knows open notes can be a valuable tool for patients who want to ensure the accuracy of their medical records and better understand their conditions and treatment plans.
We also know that medical records can be a vital source of insight when exploring options for legal action over medical malpractice, preventable birth injuries, and serious injuries that result in long-term or permanent limitations. The new mandate will be an important step toward the type of transparency our attorneys must all too often fight to obtain.