What is Open Notes
April 5, 2021
As part of the 21st Century Cures Act passed in 2016, the federal government will soon mandate that all healthcare providers offer patients immediate access to clinical notes (meaning they could read their notes while lying in their hospital bed).
According to HealthIT.gov
Patients will have immediate access to eight (8) types of clinical notes:
- Consultation Note Contains the response to request from a clinician for an opinion or advice from another clinician.
- Discharge Summary Note A synopsis of a patient’s admission and course in a hospital or post-acute care setting.
- History & Physical Documents the current and past conditions and observations of the patient.
- Imaging Narrative Contains a consulting specialist’s interpretation of image data.
- Laboratory Report Narrative Contains a consulting specialist’s interpretation of the laboratory report.
- Pathology Report Narrative Contains a consulting specialist’s interpretation of the pathology report.
- Procedure Note Also encompasses non-operative procedures, including interventional cardiology, endoscopy, osteopathic manipulation, and other specialty procedures.
- Progress Note Represents a patient’s interval status during a hospitalization, outpatient visit, treatment with a Long-Term and Post-Acute Care provider, or other healthcare encounters
Links to Information
- Common questions about the Information Blocking rule
https://www.healthit.gov/curesrule/resources/information-blocking-faqs - Implementation of Open Notes
https://www.opennotes.org/implementation/ - Webinars - How to Write an Open Note: Research & Real-World Experience
https://www.opennotes.org/news/how-to-write-an-open-note-research-real-world-experience/ - How to Write an Open Note- Document by UCHealth - (considers alternate wording)
http://www.opennotes.org/wp-content/uploads/2020/10/2020-1020HowToWriteAnOpenNote-UCHealth.pdf - Suggestions for Implementing Open Notes in Clinical Practice-toolkit
https://www.opennotes.org/wp-content/uploads/2016/02/Klein_notes-tip_toolkit.pdf - Open Notes Toolkits
https://www.opennotes.org/opennotes-for-health-professionals/#- Pediatrics & Adolescents
https://www.opennotes.org/pediatric-adolescents-patients/ - Mental Health
https://www.opennotes.org/mental-health-patients/ - Care Partners
https://www.opennotes.org/care-partners-patients/ - Open Notes Research Tool
https://www.opennotes.org/research/
- Pediatrics & Adolescents