OurNotes invites patients to contribute to the notes that document a visit.
Creating Notes with Your Clinician
As a next step toward more effective communication, the OpenNotes movement is asking patients and their doctors, nurses, and other clinicians to create notes together. We call these “OurNotes.”
OurNotes aims to:
- Engage you more actively in your care
- Bring more focus and structure to your visits, whether face to face or through telemedicine
- Help you to share decisions with your health care providers more actively
- Make things more efficient for you and those caring for you
“OurNotes has the potential to reduce documentation demands on clinicians, while having both the patient and clinician focusing on what’s most important to the patient.”
— John Mafi, MD, MPH, David Geffen School of Medicine at UCLA
New System Makes it Easier for Patients to Talk to Doctors Wall Street Journal (2018)
The OurNotes process
OurNotes was piloted at four sites around the U.S. and has been fully implemented in just a few health systems.
If you are a patient where a clinician is participating in OurNotes, this is how the process works.
Before a scheduled visit, you will receive an OurNotes pre-visit form to fill in and forward it to your health provider. The form will ask you to:
- Review your prior open notes
- Put together a short update describing how things have gone since your last visit, and
- Think through and write out two or three important goals or questions you want to cover during the visit
Depending on where you receive your care, the form may also ask you to update information about your medications and (especially for telemedicine visits) to send in measurements you may be able to make at home, such as your weight, temperature, and blood pressure.
To find out in more detail how this works, click here.
Your providers can then review this information before or during your visit. They can either refer to it or actually import it into the new opennote that becomes the record of your visit.
We have been studying this change in practice in several parts of the country, and reports from both patients and doctors indicate that through the OurNotes process, you can both engage more actively in your care and help providers make visits more productive and efficient.
Next steps for OurNotes
OpenNotes plans to develop OurNotes educational programs for you, your families, and for clinicians. We will work with electronic health record (EHR) designers to incorporate OurNotes efficiently into both your and your clinician’s workflow. And we plan to develop mechanisms to involve your family care partners actively in OurNotes (but only if you want that to happen).
Previous studies show time and again that actively engaged patients have better health outcomes. OurNotes invites:
- Active engagement by patients (and often a care partner or family member), and
- Active collaboration between patients and health care professionals.
When you review your open notes, provide updates before a visit, and state what you hope to get out of the visit, the visit can be more focused on what’s really important to both you and your provider.
OurNotes and telemedicine
OurNotes may be very helpful for telemedicine visits. You can do important “pre-work” that a health assistant might do otherwise, and the updates and goals you send in can bring more structure to the visit, making it more efficient and effective.
- Shortly before a scheduled visit, the OurNotes form is sent to you in your provider’s secure, electronic patient portal.
- The form you fill out suggests you review your prior open notes and then asks you to a) describe briefly how things have been going, along with changes since your last visit, and b) to list 2 or 3 important questions you want to discuss during the visit.
For example, you can write about changes in symptoms or the way you are taking medications, or visits you had to specialists, emergency rooms, or urgent care units. You may have questions about whether you need a blood test or a referral.
- If you can, bring a copy of your OurNotes form to your visit – to remind yourself (and, if necessary, your provider).
The information you send goes to your healthcare provider and will become a part of your secure electronic medical record. Your providers may use some or all of it in the visit notes that they prepare.
- Triggered by the COVID-19 pandemic, telemedicine visits, whether by phone or video, have become much more common.
- The OurNotes information you send in can help both you and your providers get the most out of these visits. You may also be able to do some of the pre-work that health assistants generally do for office visits. Even though you’re physically apart, you and your providers can be prepared!
- Some information would usually be obtained in the office, and the OurNotes telemedicine form includes a section on temperature, weight, blood pressure, and blood sugar (if important for you). If it’s possible, make these measurements at home. They may be particularly helpful for an illness such as diabetes.
- Early reports: Those already using OurNotes are reporting that this new practice is indeed very helpful for telemedicine visits.
It’s early in the life of OurNotes, and only a few healthcare providers are participating. But the numbers are expanding rapidly, and you may want to suggest that your health team look into it.
Before your visit, you can fill out the OurNotes form to help prepare. And if you are not registered for a patient portal, ask your healthcare provider how to get on and get connected with your health information! The combination of reviewing your past open notes and filling out the OurNotes form before a visit can make a real difference in your care!
How have you been since your last visit?
BP has been pretty good: Feb 24 118 / 78, Mar 7 108/78, Mar 18 114/78. I was not feeling well all of Jan and Feb, cough/very low energy. Eventually got worse with fever, chills and came in – tested positive for flu. Chest X-ray was OK. Got Tamiflu. Feel much better now. BTW: I had been coughing for about 6 months, maybe more. Originally thought it was connected to meds, but I don’t cough at all now.
What are the most important things you would like to discuss at your visit?
- Is it possible to still get a flu shot?
- Should I get my potassium level checked?
- Renew prescriptions
“Day 1 of Telemedicine! Overwhelmed with trying to fit all the contents of a usual office visit into the time allotted, I was thrilled to see that one of my patients had completed her OurNotes entry! Because of this, I was able to ‘walk into’ the visit with confidence in what lay ahead. I knew what her concerns were and what the focus should be. We had plenty of time to get to her ‘list’ and also to my list of routine health care maintenance issues…and to chat about the COVID crisis and how we were each coping. What a difference from the other visits into which I ‘walked’ unprepared!”
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