This resource is designed for clinicians who want to learn about open notes. It provides materials to help clinicians understand the benefits and risks of sharing notes with patients.
Find out how open notes may affect workflow and note writing. Learn how to make the most out of sharing notes with patients.
Patients report benefits from reading their notes. When patients read and review their health information, especially the notes written after a medical visit, studies indicate it can improve communication between patients and clinicians. It can also enhance engagement and help patients become more active in their own care. Research continues to show that engaged patients have better health outcomes.
What research says:
Inviting patients to read their doctors’ notes: A quasi-experimental study and a look ahead | Ann Intern Med (2012)
OpenNotes after 7 years: Patient experiences with ongoing access to their clinicians’ outpatient visit notes | J Med Internet Res (2019)
Open notes improve trust. A study published in BMJ Quality and Safety showed that 99% of patients felt the same or better about their clinician after reading notes, even after reading as few as one note. Older, non-Caucasian patients with worse self-reported health and fewer formal years of education reported the most dramatic positive effects. This suggests that the simple act of inviting patients to read their notes has the power to break down barriers and improve health equity. More than half of clinicians felt that patient satisfaction and trust increased with open notes.
“Although some people worry that poorly written, offensive, or even erroneous notes might erode trust and damage the patient-doctor relationship, studies suggest the opposite. Overall, patients continue to feel the same or better about their doctors, and clinicians believe sharing notes is a way to improve patient satisfaction, trust and safety.”
—Sigall Bell, MD, Director of Patient Safety and Discovery, OpenNotes
When doctors share visit notes with patients: A study of patient and doctor perceptions of documentation errors, safety opportunities and the patient–doctor relationship | BMJ Qual Saf (2017)
Open notes can improve note accuracy and help identify mistakes. Open notes can provide a way for patients and their care partners to make health care safer by identifying inaccuracies in the record. Clinicians review thousands of notes, but patients review only their own. Now that patients have the ability to review records, there is far more potential for enhancing communication and safety partnerships between patients and clinicians. Open notes can help identify documentation errors and prevent missed follow-up tests or referrals in the gaps between visits.
Patients know themselves best. Reviewing their own notes helps them identify and report documentation errors that may be clinically important.
What research says:
“It doesn’t make me lose confidence in [clinicians] and, in fact, I think I respect them more for admitting that there was a mistake and apologizing for it rather than sort of brushing it under the table.”
—Eileen, a patient
Open notes can empower patients as safety partners and increase transparency and inclusivity. As demonstrated in studies addressing open disclosure of medical errors, open and honest communication may help decrease litigation. Open notes may also build trust, an important factor in minimizing, and at times preventing, conflict.
What the research says:
“I felt like my care was safer, as I knew that patients would be able to update me if I didn’t get it right.”
—A clinician
U.S. experience with doctors and patients sharing clinical notes | BMJ (2015)
When doctors share visit notes with patients: A study of patient and doctor perceptions of documentation errors, safety opportunities and the patient–doctor relationship | BMJ Quality & Safety (2017)
Open notes can be a critical resource for care partners (caregivers). The growing need to engage caregivers and care partners more effectively in health care is documented in the September 2016 National Academies of Science, Engineering and Medicine (NASEM) report Families Caring for an Aging American, as well as in articles from the AARP and the New York Times.
Family members and other care partners are among the most vigilant of health system stakeholders. Work led by Jennifer Wolff, PhD, at the Johns Hopkins Bloomberg School of Public Health, demonstrates the benefit of shared access to notes.
What the research says:
Patients of all ages elected to share access to their patient portal account.
Wolff also found the benefits of open notes reported by care partners were comparable to those noted by patients themselves. Open notes appear to offer an invaluable tool for improving communication and continuity of care, while making the patient–care partner therapeutic alliance stronger through more productive discussion and greater agreement about plans for care.
What the research says:
Inviting patients and care partners to read doctors’ notes: OpenNotes and shared access to electronic medical records | J Am Med Inform Assoc (2017)
Patients, care partners, and shared access to the patient portal: Online practices at an integrated health system | J Am Med Inform Assoc (2016)
Clinicians report little change in workflow. Many clinicians are concerned that open notes will increase their workload. They worry about the length of the visit, increases in email traffic, and having to change the way they document visits.
Through our research and listening to the experiences of many health systems, the vast majority of clinicians report neither longer visits nor increased email traffic. If they notice a change at all, they are more likely to state that patients are more prepared for visits and more engaged in their care.
About 20% of clinicians do report making some changes in the way they document, though most of those changes are described as minor, appropriate, and productive. For example, they note reducing the use of acronyms and potentially judgmental language, as well as defining medical terms and making language simpler where appropriate. Nevertheless, some data suggest that writing open notes feels like it takes more time, even though studies using time stamps or character counts show very little change in the time clinicians spend writing notes.
The Views and Experiences of Clinicians Sharing Medical Record Notes With Patients | JAMA Network Open (2020)
Open notes sounds great, but will a provider’s documentation change? An exploratory study of the effect of open notes on oncology documentation | JAMIA Open (2021)
Increased transparency can improve notes. Since HIPAA entitles virtually all patients to obtain copies of their complete medical records at any time, it is always best to write notes with the assumption that patients may read them. In the initial OpenNotes study, most clinicians reported that they did not change the way they wrote their notes.
A pre-open notes implementation study survey revealed that 50% of clinicians volunteering for the study anticipated that open notes would impact their note writing. However, after a year of experience with open notes, only 20% reported changing what they wrote. Most of the changes reported were minor. Moreover, patients did not expect clinicians to write notes differently. They often reported researching things they didn’t understand, or bringing them up at their next appointment. In a more recent study, about a third of clinicians reported making changes to their note writing, while two thirds reported no change.
Over time, many clinicians do report changing the way they write their notes, most often to provide clarity. Most who say they’ve changed the way they write believe the changes have made the notes better, not just for the patient, but for other clinicians who also rely on the notes.
Some clinicians report that they have changed how they document potentially sensitive topics. These include mental health and illness, obesity, substance use disorders, sexual history, driving privileges, suspicions of life-threatening illness, and suspected elder, child or spousal abuse. These are not new dilemmas, but they gain urgency in an era of transparency.
Specific Suggestions for Writing Notes
Your patient is now reading your note: Opportunities, problems, and prospects | Am J Med (2016)
The Views and Experiences of Clinicians Sharing Medical Record Notes With Patients | JAMA Network Open (2020)
Optimize the EHR and patient portal. Now that you are sharing open notes, there are many opportunities to create efficiencies for you and your patients. Take advantage of the opportunities open and transparent communication can offer.
Reading the notes helps patients remember treatment plans. Patients also say note reading helps them take their medications as prescribed. Many patients say they email or call their clinicians less because their questions are answered by reading their notes. Furthermore, both clinicians and patients report that engaging with notes helps set the agenda, makes the visit more efficient, and helps both parties feel more satisfied with the visit and ongoing relationship.
Messaging patients about the benefits of communicating using the portal, as well as access to open notes, can be an effective way to increase portal registration. We also suggest sending patients home with printed materials and providing in-person support at office visits to help patients register on the portal.
Promote open notes to patients. For optimal success, you should communicate with patients about what open notes are and the potential benefits of reading notes. For a comprehensive set of suggestions and materials for communicating with patients, check out our Communications Toolkit.
The invitation alone is important. We find that the simple act of inviting patients to read their notes can in itself mean a lot. Research indicates that overall patient satisfaction and trust improves with note sharing. And, with as little as one shared note, patients traditionally considered among those most vulnerable report the biggest positive change in their relationships with clinicians.
Talk about the notes. Taking a few minutes at an appointment to talk about notes can strengthen your relationship with your patient. Checking in to see if a note accurately captures a visit can promote mutual understanding and allow you to gauge the patient’s understanding of the care plan.
Create an open notes button. Even the most tech savvy patients find many patient portals difficult to navigate and give up before locating the information they’re looking for. Calling out “open notes” can help patients get where they need to go. If possible, create an “open notes button” that takes the patient from the portal landing page directly to the notes to ensure that they won’t get lost.
Assess satisfaction. To understand how your patients feel about using their notes, consider adding questions about open notes to your patient surveys. Use this as an opportunity to learn about the ways they want to engage with their health information.
Send email reminders. To better understand how your patients feel about using their notes, send them email reminders. We have learned that sending an email or text to patients when a note is signed and ready to read is highly effective for keeping patients engaged with their medical information. Institutions that send reminders/alerts have a read rate roughly three times that of practices that don’t.
Get feedback. Work with a staff member, for example, a patient relations staff person, to streamline processes for patient feedback, especially as it relates to helping patients locate their notes on the portal, or to correct inaccuracies in the record.
“When I read the notes, I realized I hadn’t described my daughter’s condition in a way that helped the doctor understand what she needed. I was able to go back and clarify so we could develop a better treatment plan.”
—Amy, a mom
There are many ways to communicate with patients about open notes. You can:
Download Presentation Videos
Safety video
Adherence video
Caregiver video 1
Caregiver video 2
Mobile Users video
Mental Health video
Except where otherwise noted, the content by OpenNotes is licensed under a Creative Commons Attribution 4.0 International License.
