What is a note? What is Sutter Health changing about OpenNotes?
As part of a visit or any discussion with you, your healthcare provider writes a note summarizing the most important information discussed, such as details about symptoms, a description of the examination, an overview of relevant test results, and details about the diagnosis, treatment plan and next steps. The movement to make these notes available to patients began in 2010. This practice is called OpenNotes. Studies have shown that patients like open notes and report many health benefits.
You have the right to keep your notes and results private. If you do not want any specific notes or results to be available in MHO, you can simply ask your care team not to release them. To learn more, click here: https://www.healthit.gov/topic/information-blocking
When will notes be released?
Notes will become available in MHO at the end of each visit with your care provider once they are signed by a healthcare professional.
How does an OpenNote affect confidentiality and privacy?
An OpenNote does not change the private relationship you have with your healthcare team. Only you, those you have granted proxy access (see below) and the care team involved in your care can access your note.
What does change is your ability to access, use and share your information. It is easier to share your medical information with a care partner, family member, or others if you choose. You are in control of who has access to your note, which means you are in control of your privacy.
To help ensure your privacy, please remember to:
- Keep your MHO login ID and password private; and
- Wherever you access your MHO account, be sure to exit by selecting “sign out” or “log out” when you are done.
For tips on making the most of open notes, click here.
How does an OpenNote affect confidentiality and privacy for my child’s information?
Doctors, nurses and other healthcare professionals involved in your child’s care already have access to the information in their medical record. They operate under strict confidentiality rules, and an open note does not change that relationship.
Parents and care partners can choose to share medical information with others involved in a child’s care. This can keep families, caregivers, and specialists informed and up to date on treatments and progress. This may be especially important for patients with multiple specialists.
To help ensure the privacy of your child’s health information, keep your MHO login name and password private, and whenever you look at your child’s health record, always remember to sign out.
How is a clinical note the same or different from the After Visit Summary?
For many years, patients have had the right to request clinician notes and results through a request to Health Information Management (HIM). What’s new is that effective Oct. 29, 2020, most clinical notes and results will be released immediately in electronic form in My Health Online. This practice is called “OpenNotes” and first began in 2010. For several years, many Sutter clinicians have released their notes to patients after visits. Clinical notes provide different information than what is included in an After Visit Summary (AVS). While the AVS contains a summary of a patient’s visit, including orders placed, instructions, etc., a clinical note provides a direct view of the clinical observations and assessment of your health written by the healthcare professional to document a patient visit. This includes virtual, phone and in-person visits. The new law will require all healthcare professionals to practice open notes.
To learn more about OpenNotes, click here.
What if I have questions about the information in my note?
The best way to understand your notes and be certain everything is correct is to ask your care team to review notes with you at the end of your visit. If you have questions about your clinical note after the note is posted, write them down. You can send your question to your clinician’s office by message through MHO or discuss them at your next appointment. You can also ask your doctor, nurse or other healthcare professional for websites or other resources that might help you better understand your note. For more information about how to make the most out of these notes, click here.
I can’t see any of my notes or a specific note I expected to see. Why?
If you don’t see a specific clinical note, it is possible your provider did not complete or sign it yet. Both are required before notes can be released to MHO.
Additionally, there are specific reasons why your provider may elect not share a note. They are:
- If a provider has concern that releasing a note would result in a harm to the life or physical safety of the patient or another person.
- To respect privacy, meaning the patient (or proxy) has requested that the note not be displayed to MHO.
Will I see notes from all of my providers, or just certain parts of Sutter Health?
You should see notes and results from all Sutter healthcare professionals providing direct care to you. Currently Home Health services, and some surgical hospitals use different electronic health record systems, and their clinical notes are not yet available through MHO. If you require access to these records, please contact that care center.
California sensitive results (HIV, Hepatitis antigens, pathology results, and abuse of drug results) will not be shared immediately but are available to be released at patient request. Please submit a request to your provider if you would like these electronically released to MHO.
Historical notes documented prior to 10/29 will not be immediately available within MHO; however you may request electronic access to these records through the HIM department here: https://www.sutterhealth.org/for-patients/request-medical-record
What should I do if I think I may have found an inaccuracy in my note?
If you find what you believe to be an inaccuracy or error in your clinical note that you believe should be corrected, please contact the Health Information Management (HIM) department by email at S3ROIDept@sutterhealth.org or by calling Sutter Health Patient Services toll free at (855) 398-1631, Option 3, to speak with an agent about requesting an amendment to your medical record. HIM will send you an official amendment form along with instructions on how to complete it and where to return it.
Can I search my notes by term, time period, clinician name, etc.?
Not at this time. You can view After Visit Summaries and notes in MHO by going to your Health Record and then Appointments and Visits. Your appointments will be separated by date. MHO does not currently provide a tool to search text across appointments and visits.
You do have the ability to sort past visits by provider, department, or specialty and the list will show up in chronological order. Each encounter will have an icon indicating whether or not there is an attached note.
How can I learn what the meaning is of the medical terminology and abbreviations in my notes?
Check out medlineplus.gov for a list of common medical abbreviations and acronyms. You can also write down questions for your care team and share with them during your visit.
English is not my preferred language. Can I access translations of my notes in different languages?
Not at this time.
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