Why Should Patients Review Their Doctor’s Notes?

The doctor-patient relationship, though bound by strict regulations and legal duties, can vary widely. Your doctor’s bedside manner may be personable and matter-of-fact, or may be lacking in terms of clarity, insight, and whatever else you might be looking for when selecting the right provider.

No matter what your doctor-patient relationship may look like, however, growing research is showing just how important it can be to go beyond what a doctor says during office hours – and why reading and reviewing doctor’s notes can actually enable patients to improve their health.

Reading Your Physician’s Clinical Notes

A recent article from NBC and Kaiser Health News dives into the doctor-physician relationship and why it’s so critical for patients to read their physician’s notes. A few of the most important reasons include:

• Study-supported benefits – Researchers have found that reading physician notes can help patients improve their health. Though there are many theories and possible reasons as to why, much of the research thus far notes that seeing things in “black and white” can help patients understand the gravity of their situations, or the need to take more decisive action when it comes to improving their own health. One example cited in the article was a woman who, despite knowing she was overweight, took real action to shed the pounds and lower risks of preventable disease when she saw “clinically morbidly obese” written in her doctor’s notes.
• Unvarnished truth – Doctor’s may be highly educated medical experts who adhere to strict guidelines of care, but they can go about speaking with patients in vastly different ways. This may include tempering tough news in a more informal manner, condensing highly technical medical information into terms and concepts they think patients will better understand, or “beating around the bush” when treading lightly on sensitive subjects. Clinical notes can be much more “to-the-point” and compelling than what doctor’s may verbally communicate, and can help patients better understand their current state of health, the seriousness of any conditions or risk factors they may have, and what they can do about them.
• Details vs. summaries – Patients generally leave their doctor’s visit with a rough outline of what the physician said, either orally (which can be forgotten) or written (which can be sparse and limited to a list of medications and reminders to make follow-up appointments). Doctors’ clinical notes, on the other hand, contain many more details than those summaries; from what’s entered into records after a visit to a medical history, current health issues or complaints, doctors’ opinions on what’s happening and how it can be treated, and more.

OpenNotes, an international movement designed to encourage note sharing between patients and clinicians, has embarked on a research project to put the importance of clinical notes into perspective. In one study conducted by the group, researchers found the majority of patients who reviewed their physician’s notes reported feeling more in control of their care, and were more compliant with taking medications or heeding advice. A very small percentage (under 8%), reported that clinical notes only caused them to be confused, worry about their health, or feel offended.

Although there are many benefits to reading doctor’s notes, and laws (HIPPA to be precise) which allow patients to obtain and review those notes, actually accessing them isn’t always easy. In fact, studies have found policies on medical record requests can vary widely from provider to provider – some fail to meet deadlines for delivery, and others charge fees far in excess of recommendations.

By addressing these issues and breaking down barriers to i medical record access, both patients and providers can benefit – patients in terms of their health and well-being, and providers in how mindful they are when choosing the words they use in patient records.

Medical Records & Medical Malpractice

As a firm that represents victims and families in medical malpractice and birth injury cases across the country, our team at The Becker Law Firm knows it’s a wise decision for patients to review their medical records. The detail and indelibility of these records not only allow patients to improve their health care experiences and personal health, but also identify lapses in quality of care, mistakes, fraud, or negligence that can provide critical evidence in medical malpractice claims.

Our attorneys have become skilled at interpreting medical records, and evaluating their role in supporting claims against negligent health care providers who cause patients preventable harm and losses. If you have questions about medical records, malpractice, and a potential case of your own, contact us to speak with a lawyer.