What Are Visit Notes?
When you see doctors or other clinicians for an appointment, you may notice them recording notes by hand or on a computer during the visit. These visit notes, which summarize what was discussed between the clinician and patient and what the clinician found or measured during the appointment, become a part of your medical record.
Visit notes may include commentary, such as:
- What the patient and the clinician discussed during the office visit, including the health problems the patient reports, the doctor’s physical exam findings, diagnosis, and the treatment plan.
- Why the doctor or other practitioner ordered a specific lab test or prescribed a certain medication.
- Other information pertinent to the care plan, such as coordination of care, specific arrangements for caregivers, and non-medical needs.
- What needs to be done after the visit, such as additional tests or studies, follow up appointments, or referrals to a specialist.
What is the difference between a note and a visit summary?
A note contains a detailed account of your visit, including the history, exam, relevant lab or study findings, and the clinician’s assessment and plan of care.
A visit summary gives you a more limited snapshot of your visit including the “vital signs” recorded at the visit, a list of your medications and a summary of follow up visits that are already scheduled. The visit summary sometimes also includes specific instructions your doctor provides for you.
Together the visit summary and your note provide a far more complete picture of your visit.
Don’t patients already have access to medical records?
Patients have access to ever-increasing amounts of health information, such as their laboratory results, medication lists and other parts of their medical record. Notes are the thread that tie together many pieces of information in the medical record.
But patients rarely have easy access to the notes clinicians write about them. And while patients have the right to review their medical records, including the notes clinicians write, most people generally don’t ask and most clinicians don’t offer.
“Everything that we have and know about you as a patient, you should have access to.”
Kevin Tabb, MD, President and CEO, Beth Israel Deaconess Medical Center in Boston, MA