Always Read Your Doctor’s Notes. Here’s why.

Doctor taking notes. Patients should always read their doctor's notes.

By Terri Dreher, RN

We all know that when we visit a doctor, it’s important to clearly communicate the issues we’re having, never lie, and make sure we understand (and follow) our treatment plan.

However, we should do something else that’s not as obvious:  Read our doctor’s notes. If we don’t, we could be missing crucial information.

Let’s say you request your doctor’s notes from a recent visit, and you see terms like “imp,” “po,” and “F/U”.

Feeling insulted? Don’t be. These terms are shorthand for standard medical terminology: impression, par os (Latin for “by mouth”), and follow up.

Reviewing and understanding terms like this, and everything else in your doctor’s notes, brings a lot of benefits.

For example, studies indicate that most patients remember less than half of what they discuss with their medical providers. Reviewing the notes helps ensure that you haven’t missed important information and that you and your medical team are on the same page. 

The more connected you are with your medical team, the more you’re able to manage your own health and well-being.

According to the nationwide nonprofit OpenNotes, which seeks to make it easier for patients to access their notes and encourages doctors to share them, other benefits of reviewing your doctor’s notes and medical records include:

  • The ability to ask better questions and make more confident decisions
  • More effective sharing of medical information with family members, other care partners, or new doctors
  • Better communication and partnership with caregivers of elderly parents and children
  • More trust between patients and their medical caregivers
  • The opportunity to identify mistakes and make sure records are accurate.

Medical Records More Accessible Than Ever

The good news is that obtaining your doctors’ notes and other medical records is easier than it used to be. 

OpenNotes has partnered with a company called Ciitizen. Their free service, Where Is My Medical Record?, is a web-based resource to help patients access their doctors’ notes and medical records.

The website explains “the complicated process of requesting records” and “offers step-by-step guidance about what constitutes medical record information blocking,” says Catherine DesRoches, executive director of OpenNotes and an associate professor of medicine at Harvard. Patient advocates, who are experts at navigating the health care system, are also there to assist.

And here’s another welcome development:  Medical notes and records are more widely available in general because of the use of electronic health records (EHR). 

You may have noticed that your health practitioner is typing notes into a laptop or desktop computer during your visit, rather than writing in a paper chart. Which, if you believe in the old saw about doctors’ terrible handwriting, is a step forward.

In some practices and hospitals, a medical scribe might accompany a doctor with a rolling computer stand, taking on the clerical responsibilities of EHR and helping to gather and record patient information.

Perhaps because of some of the terminology, many doctors still aren’t comfortable giving patients access to their notes. But under the Health Insurance Portability and Accountability Act, you’re entitled to your medical records. 

As of April 2021, most providers are required by law to make them available electronically, such as through secure internet patient portals. You can still request paper copies, of course.

Take the First Steps Now

If your doctor’s practice or hospital has an electronic patient portal, learn to use it. 

At your next visit, ask your doctor to turn the computer screen toward you to share what’s being written. Some doctors might even ask you to contribute to the notes before your appointment by, for example, listing your concerns in order of priority.

Afterward, when you review your doctor’s notes, ask for clarification on anything you don’t understand. And before you feel insulted by an unfamiliar term, look it up. You’ll find that S.O.B. doesn’t mean what you think – it stands for “short of breath.”

Regularly reading your doctor’s notes will help you and your doctor communicate better, help you take control of your health care journey, and potentially lead to better health outcomes. And that’s what we’re all shooting for. TwP

Teri Dreher, RN, is a patient advocated with NShore Patient Advocates. She is the author of How to Be a Healthcare Advocate for Yourself & Your Loved Ones, available on Amazon. She would be happy to offer Thrive With Paralysis readers a free phone consultation. Reach her at Teri@northshorern.com.

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