With doctor and hospitals now using more electronic medical records and with the movement in healthcare toward greater transparency, patients have greater access to their medical records. Therefore now, more than ever, medical records (and open notes) take on a new and important role in healthcare delivery and treatment.
Medical records are a complex component of our healthcare system that cross the domains of many areas: care and treatment, insurance and billing, patient rights, regulations, legal issues, etc. Dr. Gordon brings up many important points in this article about open medical records. A psychologist mentioned to me that one point not highlighted in the article is that open notes might help cultivate more respectful attitudes in treaters toward their patients. The way a note is written certainly affects the way we think and talk with each other about cases, and open notes can decrease the frequency of treaters’ writing something dismissive or judgmental in charts.
Better Health Advisors believes in the following principles with regard to electronic medical records:
- When managed thoughtfully, patient access to medical records is a valuable tool for optimal care and treatment.
- Hiding information, be either the care team or the patient can be suboptimal to care and treatment. The record needs to reflect the truth.
- Insurance companies should not be influenced by what’s in the record or punish patients based on medical information in the record.
- Errors can be identified if the record is carefully reviewed by a patient or health advocate.
- Mental health can sometimes be more complicated than other aspects of healthcare and needs special attention and focus in recording the care of a patient.
- Greater dialogue is needed. Providers and patients need more dialogue more about medical records. We need to talk more about what is in a record, why it’s included, what’s not included and how it’s used. In addition to discussions in doctor’s offices about a patient’s record, we also need broad national dialogue from multiple perspectives.