How Sharing Clinical Notes Affects the Patient-Physician Relationship
On April 5, a new federal rule turned OpenNotes goal into the law of the land.Now, virtually every US medical practice and health system must make all information in electronic health recordswith a few exceptionseasily accessible to patients at no charge. The mandate, part of the 20th Century Cures Act enacted in 2016, originally was supposed to go into effect November 2, but the US Department of Health and Human Services (HHS) at the last minute extended the compliance deadline due to the COVID-19 pandemic.The US Core Data for Interoperability lists 8 types of clinical information that must be shared: consultation, discharge summary, procedure, and progress notes; imaging, laboratory report, and pathology report narratives; and history and physical. The rule doesnt apply to psychotherapy notes kept separate from the patients health record or notes compiled in reasonable anticipation of use in a civil or criminal court case or an administrative proceeding. In addition, the mandate permits withholding information if doing so will substantially reduce the risk of harm to a patient or another individual, such as in a domestic abuse situation.