Designing Your OpenNotes Program

Before implementing open notes, medical leaders need systematically to think through how the practice of sharing visit notes will work at their institution. Local organizational culture will likely influence several policy decisions. You should communicate these policies to patients and clinicians before implementing open notes. Please see the Patient FAQ and the Clinician FAQ documents as examples of ways to explain these policies.

We have included a list of important questions to help you get started. To ensure that stakeholder perspectives are heard and accommodated in policy design, you may wish to invite clinician and patient representatives from your institution to participate in policy planning.

Which clinicians will share their notes?

  • Will you open only doctors’ notes? Or, will you open other clinicians’ notes, e.g., nurses, nurse practitioners, case managers, social workers, physician assistants, occupational and physical therapists, clinical pharmacists, dieticians, or others who write notes?
  • Will you open notes written by fellows, by residents, by medical and nursing students, other trainees?

Which departments or settings will share notes?

  • Will you open notes in all departments: Medicine, Surgery, OBGYN, Neurology, etc.? Or, will you exempt some departments? Will you include the Emergency Department?
  • Will you include “behavioral health” notes (e.g., notes from social work or psychiatry)?
  • How will you handle pediatric notes and rules governing pediatric note access?
  • Will you restrict open notes to ambulatory settings or include also inpatient notes?

What types of notes will you share?

  • Will you open all types of notes (phone, office visit, letters, etc.) or limit them to certain encounters?
  • Which patients will have access to their notes?
  • Will you open notes to adult patients only?
  • Will you include pediatric and adolescent patients?
  • Will caregivers, family members, proxies, or other patient advocates have access, with patient permission?

How will you share notes with patients?

  • Will you notify patients when notes are available for review? If so, will you notify patients immediately after a note is signed, before the next visit, or both?
  • Will you allow clinicians to exclude patients? If so, how will you communicate this decision to patients?
  • Will you develop mechanisms for clinicians to make some notes or portions of notes “private,” or “closed,” so that individual patients cannot access them online?
  • How will you manage patients’ requests to change or amend their notes?
  • Will patients be able to control exactly what information caregivers and families may access?

 How will you implement open notes?

  • Will you mandate it across departments, divisions, clinics, etc.?
  • Will you allow clinicians or departments to “opt-out” or “opt-in” to open notes?
  • I you allow clinicians to opt-out of open notes, who will grant them permission to opt-out?
  • Will you allow clinicians to pilot open notes?
  • When multiple providers (e.g., advanced practitioner and physician) sign notes, do both providers need to participate in open notes for patients to view the note?
  • Will you include notes signed before your organization’s open notes start date?

How will you collect feedback from patients and from clinicians about the open notes experience?

  • Will you designate a specific contact (e.g., Patient Relations staff), for patients with concerns about their note who wish to speak to someone other than their clinician?
  • How will you assess the impact of open notes on patient and clinician satisfaction?
  • Will you develop metrics to measure the impact of open notes on your institution?
  • How will you share feedback from patients and clinicians with other patients and your organization?
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