The 21st Century Cures Act mandates that patients have fast, electronic access to the following types of notes:
- Discharge summaries
- Physical examinations
- Imaging narratives
- Laboratory and pathology report narratives
- Procedure and progress notes
The law means that inpatient and outpatient notes will be released immediately and that patients will have immediate access to testing and imaging results. Traditionally doctors have written notes using medical lexicon, including a lot of abbreviations and jargon for efficiency’s sake. Now that patients will read the notes, clinicians may have to spell out things in lay terms, alter their writing so as not to offend and generally do more work! Steven Reidbord, MD, a psychiatrist in private practice in San Francisco and a lecturer at California Pacific Medical Center, is particularly concerned about the impact of open notes on progress notes which he calls a tool to develop strategies and make observations while working with a patient.
In a study published last year, researchers analyzed notes written by oncologists before and after adoption of open notes. They found that on average, clinicians did not change their note writing. To be clear, the new law does not mandate clinicians change their writing style. It will be interesting to see how many patients actually take advantage of the new law and how many trust their physicians to be doing the right things. That said, this could be a plaintiff attorney’s hay day!
Stay well, stay safe and stay tuned!