When Patients Read Their Story in Clinical Notes
Authors: Heather E. Gantzer
Journal: Annals of Internal Medicine (2020)

EditorialsJanuary 2021When Patients Read Their Story in Clinical NotesHeather E. Gantzer, MDHeather E. Gantzer, MDPark Nicollet Clinic, St. Louis Park, Minnesota (H.E.G.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-6632 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Current clinical notes often attempt to check off many requirements related to reimbursement: documentation of current medications, documentation of organ system review, documentation of test results, documentation of fulfillment of performance measures, and, somewhere in the mix, an assessment and plan. Social history is often relegated to simply updating smoking status.But as Blease and colleagues point out in their article (1), the cloak that effectively covers many notes will be lifted on 2 November 2020, when the 21st Century Cures Act is implemented and patients are to have ready access to their medical record, including the clinical notes (2). ...References1. Blease C, Walker J, DesRoches CM, et al. New U.S. law mandates access to clinical notes: implications for patients and clinicians. Ann Intern Med. 2021;174:101-2. doi:10.7326/M20-5370 LinkGoogle Scholar2. Sweeney Anthony E. The Cures Act Final Rule: interoperability-focused policies that empower patients and support providers. HealthITBuzz Blog. 9 March 2020. Accessed at www.healthit.gov/buzz-blog/21st-century-cures-act/the-cures-final-rule on 1 October 2020. Google Scholar3. Gantzer HE, Block BL, Hobgood LC, et al. Restoring the story and creating a valuable clinical note [Editorial]. Ann Intern Med. 2020;173:380-382. doi:10.7326/M20-0934 LinkGoogle Scholar4. Delbanco T, Walker J, Bell SK, et al. Inviting patients to read their doctors' notes: a quasi-experimental study and a look ahead. Ann Intern Med. 2012;157:461-70. doi:10.7326/0003-4819-157-7-201210020-00002 LinkGoogle Scholar Author, Article, and Disclosure InformationAffiliations: Park Nicollet Clinic, St. Louis Park, Minnesota (H.E.G.)Disclosures: The author has disclosed no conflicts of interest. The form can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-6632.Corresponding Author: Heather E. Gantzer, MD, 3800 Park Nicollet Boulevard, St. Louis Park, MN 55416; e-mail, [email protected]com.This article was published at Annals.org on 13 October 2020. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoNew U.S. Law Mandates Access to Clinical Notes: Implications for Patients and Clinicians Charlotte Blease , Jan Walker , Catherine M. DesRoches , and Tom Delbanco Metrics Cited byCoronavirus - A Crippling Affliction to HumansThe US opened up access to health records—how do patients use them? January 2021Volume 174, Issue 1Page: 115KeywordsConflicts of interestDisclosureElectronic medical recordsEmotionsFearHabitsHand strengthMedical educationPerformance measuresSystematic reviews ePublished: 13 October 2020 Issue Published: January 2021 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...