FindLaw KnowledgeBasePublished: 2012-05-07
While patients legally have access to their medical records, the process to acquire doctors' notes can be difficult, and some doctors are reluctant to share. Doctors who are not in favor of an open environment of patient medical records worry their medical assessments will be misinterpreted by patients, and others worry they would have to edit their written records to protect themselves from possible medical malpractice claims. Patients, on the other hand, believe better access would help them be more active in the management of their health.
Doctors’ notes often include a patient's medical history, a record of what was discussed between the patient and doctor during the visit, and the doctor's insight into the state of the patient's condition and health. According to a recent study published in the Annals of the Internal Medicine, many patients wish they knew the information contained in their doctor's notes, but a majority of doctors who participated in the same survey were not inclined to share the information.
Medical professionals today often act as the gatekeepers to patients' medical information and its interpretation. But, a professor of medicine at Harvard Medical School wanted to challenge the asymmetric management of patient medical information between doctors and patients by conducting a survey on patient and doctor attitudes towards open notes. Although patients have the legal right to doctors' notes and medical professionals want patients to be involved in their own health care, regular access to doctors' notes is not widespread.
The control of patients' records by doctors is rooted in the doctors' medical expertise and ability to interpret information such as test results, but that tradition can also mask information helpful to patients. Doctors in opposition to greater note transparency express concerns that their interpretation of patients' health and medical conditions may confuse patients and may trigger more patient questions. Doctors also worry that the misinterpretation of notes by patients may lead to potential medical negligence claims.
Among medical facilities with open notes policies, like the University of Texas, many of these concerns have not emerged. According to Time: Healthland, open notes have not created more questions from patients but have helped patients answer their own questions, saving doctors time. The greater transparency has not caused an increase in malpractice claims, and insurance premiums have dropped since patient records at the University of Texas became digital.
Open notes have even served as a motivational tool for patients because reading a record of their health helps patients make a change in behavior.
Even though the initial survey only recorded patient and doctor attitudes towards open access to office notes, the same research team has also recorded how doctors and patients use open health records and plan to report on the findings in the future.
If you believe you’ve suffered a medical error, contact an experienced medical malpractice attorney to review your legal options.