Ask a Researcher: What Patients Need to Know About Access to Doctors’ Notes

Did you know that as of April 2021, all patients have electronic access to their doctors’ notes from medical appointments? This increased access to information is aimed at improving patient care, as well as patient engagement in their healthcare.

Peter Winkelstein, MD, MS, MBA, Executive Director, Institute for Healthcare Informatics, and CTSI Steering Committee and Board member, discussed the news in a recent article on The Paper Gown, a website exploring the patient experience. As the article explains, the 21st Century Cures Act mandates that healthcare providers must make medical records readily available to patients.

Even before the new provisions, Winkelstein told The Paper Gown that many doctors were increasing their patients’ access to notes, or allowing them to see their screen while typing.

“A lot of people have adopted the idea that patients should have access to this, and that it improves care because a patient can say, ‘That’s not quite what I meant,’ and it makes patients more comfortable that nobody is keeping things from them,” Winkelstein said.

In a follow-up interview with Buffalo Research News, Winkelstein stressed the value of having access to notes.

“If a patient sees something in the note that they do not understand or that does not appear to be correct, the patient should reach out to their doctor for clarification,” Winkelstein says. “Many doctors will go over their notes with the patient before leaving the office as a way of minimizing the chance of a misunderstanding and to be sure they have communicated well.”

Winkelstein adds that “misunderstandings are relatively rare; most of the time the doctor’s notes are pretty straightforward.”

Ultimately, Winkelstein sees increased access to doctors’ notes as a positive development for patients and allows for transparency.

“The better that a patient understands their health, the better they will be at managing it,” he says. “Informed, activated patients have the best outcomes.”

Learn more about the new provisions of the 21 Century Cures Act here.