• Should Patients be given access to physician notes

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    Nurse explaining to patient

    Do patients need to have access to the notes made by doctors and nurses?

    This promises to be controversial!!

    Way back in 2011, a report was published, in The Annals of Internal Medicine.

    If you are a patient, chances are you are infuriated by the secrecy (and ‘conspiracy’?) of doctors, nurses and hospitals. The commonest complaint you have is that you have not been told anything. You reassured the doctor that you would not take it badly and wanted to know exactly what is wrong with you, but the doctor keeps repeating, “You are all right, nothing’s wrong with you.”

    And this makes you even more worried, because YOU know you are NOT all right, and when the doctor doesn’t tell you anything, you now start imagining it is SO bad that they want to protect you from the news!

    The Conspiracy

    It gets worse when your family starts reassuring you; now it’s confirmed that everyone is in the conspiracy of hiding things from you!

    Now you want your reports; you will read it, try to understand it on your own, ask a close friend who spent so much time taking care of an invalid at home that she is a ‘half – doctor’ by now. Or, you will take those report and visit another doctor, who is far off and is more likely to tell you the truth.

     

    Is this person you?

    Then the chances are that you blow your top when the hospital refuses to give you your report; they treat you like a child, as if you would not be able to take care of your own report.

    One of the commonest, bitterest complaint people have with the medical system – is the refusal to give a patient her reports. Do you agree?

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    Now, where we live and work, patient’s are NOT routinely given their investigation reports.

    This is in the UAE, and I am a doctor practicing in the private sector. Many patients come to us, having undergone part of their treatment in the public sector hospitals, and they come without any papers – no investigation reports, no clinical notes – sometimes even without prescriptions!

     

    Some of the time, they have lost the prescription paper, and all they have is a polythene bag full of medicines, which they dump unceremoniously – even accusingly on your desk – as if to say, “Your medicines don’t work!” even if I am not the doctor who made those prescriptions!

     

    They have my full sympathy; I believe whatever tests are done in a clinic or hospital, they are the property of the patient and they have a right to have a copy of their own. In the hospitals where I have worked, this principle has always been applied.

    Back in our home country, India – quite a few hospitals in the private sector also don’t hand – over these reports to the patients, ostensibly to ‘keep them safe’. But it is quite transparent that they do it so as not to lose a client!

    The Study

    But this article is on a different dimension now; this study is to identify what doctors and laymen (read patients’) feel about getting access to doctors’ and nurses’ notes!

    Now this can be very controversial – for doctors, at least. Errors would not be hidden anymore! Lack of proper documentation cannot be kept a secret. The study finds that “..Overall, 69% to 81% of participating PCPs across the 3 sites and 92% to 97% of patients thought open visit notes were a good idea,…” Participating PCPs refers to those Primary Care Physicians who participated in a voluntary program where access to clinical notes was provided on an experimental basis.

    The authors further quote: “…participating PCPs and patients generally agreed with statements about potential benefits of open visit notes…”, and that “…74% to 92% anticipated improved communication and patient education,…”

     

    Among these doctors, 50% to 58% expected that open visit notes would result in greater worry among patients; far fewer patients concurred (12% to 16%).

    In this study, more than half of the participating doctors anticipated more questioning by patients as a result of this openness, but few expected to be subjected to more lawsuits.

     

    The authors concluded that the doctors varied widely in their opinions on the effect on the patients as a result of this kind of exposure to doctors notes, whereas most of the patients were far more enthusiastic about it – which is quite expected!

    LinkedIn Discussion

    Here’s a LinkedIn Discussion on this topic, and there are some strong opinions there!

     

    Some of the commenters are very enthusiastic about this, and have this to say:

    John Stafford, Health and Wellness

    “There is no question that patients should be able to access their own medical record except that the concept of a medical record is too limiting. It should be at least a health record (i.e. with notes of nurses and allied health professionals regardless of which health agency provided that care, radiological and pathological results and pharmaceuticals) and better still a wellness record where the patient can contribute their own data (e.g. home monitoring for diabetes or blood pressure) and also recording their weight, nutrition, physical activity, sleep and so on….”

    Hille Meetsma, Healthy & Active Aging by VitalinQ,

    Your Personal Health Assistant, a Social Media for Your Health.

    Hille Meetsma

    “In my opinion the individual person must be granted to have at least a copy of the medical data that is stored about him/her. The medical data also must kept stored to the ‘hospitals’ or what ever place for later use in case of an emergency or for scientific research.
    Ownership means more ‘have the right to have a copy’ then ‘i decide what to do with it’.”

     

    Dr Rajinder Kumar Bajoria
    Dr Rajinder Kumar Bajoria, Surgeon cum Sonologist at Neera Nursing Home ,Karnal

    “In my opinion there is no harm in providing the record to the patients or relatives ,it only improves quality and confidence”

     

    In your opinion, how might access to visit notes improve patient care, or would this be confusing to patients and trying to physicians?

     

    The study can be found here: http://annals.org/article.aspx?articleid=1033220

     

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