When Patients Read Their Story in Clinical Notes

When Patients Read Their Story in Clinical Notes

Current clinical notes often attempt to check off many requirements related to reimbursement: documentation of current medications, documentation of organ system review, documentation of test results, documentation of fulfillment of performance measures, and, somewhere in the mix, an assessment and plan. Social history is often relegated to simply updating smoking status.

But as Blease and colleagues point out in their article (1), the cloak that effectively covers many notes will be lifted on 2 November 2020, when the 21st Century Cures Act is implemented and patients are to have ready access to their medical record, including the clinical notes (2). …

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