Patients now have access to doctor’s visit notes: A guide to what’s inside

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What does your doctor really think about your condition and health concerns? For more than a year now, patients have been able to access and read the observations doctors write down about them during a visit.

The clinical notes can come with surprises. Patients may be amused to find out they’re described by their physician as “well-nourished,” “well-groomed,” “pleasant” or “normal-looking.”

“’He is not ill-appearing or toxic-appearing.’ That’s the best review I’ve ever received,” one man wrote on Twitter after reading his doctor’s notes.

But patients may also be taken aback by comments referring to them as “obese” or mentioning their marijuana use. One woman was shocked when she saw her doctor wrote down that she “seemed overly dramatic,” she complained on Reddit.

As of April 2021, healthcare providers must give patients access to all of the health information in their electronic medical records as part of the 21st Century Cures Act. That includes your doctor’s written comments about your physical condition during a visit, along with any symptoms and what the treatment should be.

The rules don’t apply to psychotherapy notes made during counseling sessions or when doctors believe a patient would harm another person or themselves after reading the information, according to OpenNotes, a non-profit organization based at Beth Israel Deaconess Medical Center in Boston that advocates for greater transparency in healthcare.

Doctors have been both supportive and cautious of the movement. In a 2020 survey of 1,628 clinicians, 74% agreed note sharing was a good idea.

“It does give the patient a lot more ownership of their medical condition because they can see what we’re thinking about, they understand our thought processes a little bit more, and they can see what the options are,” Dr. Sterling Ransone, Jr., a family physician in Deltaville, Virginia, and chair of the American Academy of Family Physicians, told TODAY.

But knowing that patients can now read his notes, Ransone finds he self-censors himself to avoid sounding critical or judgmental of a patient.

“It’s difficult because sometimes you have to leave a note to yourself what your concerns are, but they can cause anxiety with the patient,” he noted. “I can say that it really has changed the way that a lot of physicians write their notes.”

That means more accessible language, less jargon and more caution with certain terms that might offend or upset a patient.

Ransone no longer uses the abbreviation “SOB,” which stands for “short of breath” and instead writes out the full term in his notes. Same with “FU,” which stands for “follow up.”

The American Academy of Family Physicians has also urged doctors to write “patient could not recall” instead of describing them as a “poor historian;” “patient declines” instead of “patient refuses;” and “patient is not doing X” instead of describing them as “non-compliant.”

A guide to your doctor’s note:

The medical note has traditionally included four parts, Ransone said: The subjective findings, or what a patient said they were concerned about; the objective findings, or what the doctor actually observed during the visit; the physician’s assessment after evaluating the patient and the treatment plan.

Doctors are used to jotting down any observations that can offer clues to what’s going on. So writing down that a patient “seemed overly dramatic” can mean the person’s complaint wasn’t consistent with the degree of their symptoms and something else might be the reason for their visit that day, he noted.

Here are other descriptions patients may find in their doctor’s notes:

Well-groomed or pleasant: This can indicate mental status. “If someone comes in and they’re somewhat disheveled, it leads you to wonder why and what do I need to look into?” Ransone said. “Pleasant” means the patient was communicative and responded to social cues, he noted. Patients who are upset or sleepy could have a substance abuse disorder or another reason why they’re having trouble interacting.

Well-developed or well-nourished: “A lot of times when people look at open notes and they’ll say, ‘Well, of course I am. What does this mean?’” Ransone said. “It just means that we checked in our mental checklist… (that) those aren’t things that we need to worry about.” If a person isn’t well-nourished, it might mean they don’t have access to food or their teeth might be in such bad condition that they can’t chew and get nutrition.

Unremarkable: This is a good thing. “Unremarkable is exactly what you want to be when you see a physician,” Ransone said. “I joke with my patients all the time: You want to be the most boring patient that I’ve seen today, because that means we haven’t seen anything that is abnormal that we need to chase down.”

Obese: To a physician, the term means the patient is of a certain weight for their height and frame, which comes with a certain constellation of medical concerns, Ransone said. “There’s a stigma to obesity in society and a lot of patients really don’t want to have that on their charts… but it’s a very important piece of the puzzle for me as I’m trying to help a patient get healthier,” he noted.

Substance use: This isn’t necessarily bad. Doctors will note a patient has an occasional glass of wine, for example, to give them an idea of the person’s alcohol consumption habits. “The way that our society looks at, say, marijuana use has changed a lot over the years, but a lot of people don’t want that included in the medical record,” Ransone said. “I’d like to know if someone is smoking weed because it could affect the medications that I should give them for their health condition.”

Other health observations patients frequently don’t want on their chart include mental health issues such as depression, anxiety or bipolar disorder, he noted.

Some patients have called Ransone to ask that he change something in their note because they see it as a pejorative or they disagree with his assessment, but that doesn’t mean he’s wrong, the doctor noted.

One guide for physicians suggested telling the patient: “I’m sorry you disagree with my assessment. While I can’t change my medical opinion, if you’d like I can add that you disagree with it.”

Patients pointing out factual errors — such as noticing the note referenced a problem in the right knee rather than the left — is a completely different issue. If there’s anything inaccurate in your chart, bring it to your doctor’s attention.

In fact, patients who read their doctor’s notes may play an important role in finding errors in their records, a 2020 study published in JAMA found.

Ransone encouraged patients who are reading their doctor’s notes to keep the lines of communication with their physician open.

“Don’t necessarily assume the worst when they read things. Realize that a lot of the things that they read are open to interpretation,” he advised.



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