A recent article in the New England Journal of Medicine reports the growing trend of open access to medical notes for patients, and envisages a day when notes are truly shared – sealed with the signature of the patient alongside that of the physician in charge of their care. 100 primary care doctors in America agreed to allow 20,000 of their patients to read their notes (securely and on-line). The result? Patients had a better recall and understanding of their illness and treatment plan and none of the doctors chose to discontinue the practice at the end of the trial.
In my experience, requests to look into medical notes come rather infrequently. When one does come, alarm bells invariably start ringing, as it tends to imply dissatisfaction rather than curiosity and a desire to understand more. But perhaps it is time to move away from this territorial approach to medical notes.
The emphasis on note-taking varies across countries and the quality and legibility drastically from doctor to doctor. I’ve known colleagues to write verbosely of their findings and impressions with a happy flush of their pen at an intellectual level near to that of Dr. House, and others who document so poorly that it impossible to decipher anything of worth from the notes. As notes become electronic, as well as providing instant, legible access for multiple clinicians, providing assess to patients becomes easier.
At a dinner party recently, conversation turned to a guest’s unhappy experience as a patient, and his belief that his notes had been incorrectly documented. Open notes could improve the accuracy and quality of note-taking as well as resulting in improved trust in the doctor-patient relationship and perhaps even improving the standard of care.