Whether you’re learning about open notes and how notes can help you, getting ready to start reading notes, or are an experienced user of notes, here are some answers to questions people often ask:

Whether you’re learning about open notes and how notes can help you, getting ready to start reading notes, or are an experienced user of notes, here are some answers to questions people often ask:
After office or tele-visits, doctors, nurses and other health care providers write notes that summarize important information about you. These notes become a part of your medical record. And when a note is shared with you, it becomes an "open note." It may include:
How notes look depends on many things: who writes the note, the kind of visit, where you get care, etc. Sometimes the notes are short. Others include a complete description of the visit and may also include additional details about your health, such as past problems or test results. And due to various rules and regulations, some may include information that doesn’t seem very relevant.
Your note may have medical language that’s not easy to understand. You can find a lot on the Internet, but try to make sure it comes from a reliable source. View this list of common abbreviations to help you with medical terms. If you have questions, write them down. Follow through, whether with a friend, your doctor, or any source you trust.
Note reading may not be right for everyone. Follow your instincts. For some people, just knowing that the notes are available is enough. Thousands of patients report that the benefits from reading notes are much greater than the risks. In fact, reading notes often builds or reinforces your trust in those taking care of you. And studies show that very few people report feeling harmed by what they read.
By federal law, you have the legal right to receive and review all of your medical records, including the notes. Starting April 5, 2021, most providers are required by law to make them available by electronic means, such as through secure Internet patient portals. There are a few exceptions, but the vast majority of notes should be available, no matter what health condition you may have.
If your notes are not yet online or you don't have a way to use electronic communications, you can always ask for a paper copy.
If you still have trouble, visit whereismymedicalrecord.org, a collaboration between OpenNotes and Ciitizen.
Possible reasons include:
If it’s serious—something that could affect your care urgently—contact the office of the health care provider who wrote the note.
For other mistakes or inaccuracies, bring them to your medical team’s attention, particularly if you think correcting the note will affect your current or future care. Your healthcare provider’s office will have a process for helping ensure accuracy.
It’s important to know that open notes do not change the entirely confidential relationship you have with your health care providers. They can share your information only with health professionals who care for you and with some administrative personnel who also have the legal and ethical right to see your personal health information.
On the other hand, the information in your records is about you, and you can choose to share it with others. With ready access to your notes, it’s much easier to share your medical information with a care partner, family member, or others—but only if you choose.
To help ensure your privacy when using an online patient portal, remember to:
OpenNotes is a not-for-profit international movement started in 2009 by health professionals at Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, Massachusetts. It is supported entirely by grants from private foundations, gifts from donors, and federal research grants. OpenNotes does not develop or sell software or commercial products. Its staff includes doctors, nurses, mental health professionals, social scientists, and patients and their care partners. Those working with OpenNotes have two principal activities: They urge health care providers and systems to utilize notes to partner with patients and care partners efficiently and actively, and they study what happens as a result.
We're funded by grants, philanthropy, and supporters like you. Your entire tax-deductible donation will go to spreading the OpenNotes movement.
NEW WEBINAR
Getting It Write: What To Do Now That Patients in England Can Read Their GP Notes
Tuesday, November 1, 2022 | 8am Pacific Standard Time (PST)
11am Eastern Standard Time (EST) / 3pm Greenwich Mean Time (GMT)
While open notes have been the “law of the land” in the United States for more than a year, in England, adult patients accessing care through the National Health Service (NHS) will have access to their primary care record online for the first time starting Nov. 1, 2022.
In this webinar, we’ll be joined by open notes experts and discuss what this change means for patients and general practitioner (GP) staff in England.