When I started my medical career and as I progressed in it, the impression I had was that clinical notes were only for health care providers and should be kept out of the reach of patients.
It was a treasure available only to the chosen ones. It would never have occurred to me that a patient could take their records and make them their own.
A medical record is the set of documents that contains data, assessments, and information of any kind on the situation and clinical evolution of a patient throughout the care process.
These clinical notes have many components:
- Demographic data: name, age, etc.
- Contact information: telephone, email, etc.
- Development history: growth, motor development, etc.
- Vaccination records
- Administrative data
- Records of tests performed
About Clinical Notes
Clinical notes are written by doctors, nurses, therapists, or other healthcare professionals to describe and record their interactions with patients. They are known by various names: visit notes, clinical notes, progress notes, or medical records, to name a few.
What does the law say?
Daniel Piña, a lawyer from the Complutense University of Madrid, comments that, according to Law 41/2002, of November 14, Regulating Basic Patient Autonomy and Rights and Obligations Regarding Information and Clinical Documentation, a patient has the right to access their medical history and obtain a copy of the data contained on it.
This same official state bulletin in Spain, in its article 18 on the Rights of Access to Medical Records, makes it very clear that, “The patient has the right of access to the documentation of the medical record and to obtain a copy of the data contained in it.”
The right of the patient to access their medical history is also explicitly mentioned in the new European regulation 2016/679 on the protection of personal data.
It establishes in its article 15 that if the patient requests a copy of their history at any time, we must provide it, provided that we can verify their identity.
This is a worldwide trend. Even Americans living in such a complicated medical-legal environment are very clear about the patient’s transparent access to their entire medical history.
Under the HIPPA legislation that regulates this, individuals have a legal and enforceable right to see and receive copies of the information in their medical records and other health records maintained by their health care providers.
What does this mean for my clinical practice?
It seems quite clear that patients have the right to request access to their medical records at any time. So, the first thing is to understand and accept this fact.
Transparency has migrated to all aspects of our society and medicine is no exception.
There are studies that have exhaustively evaluated the patient’s reactions when they access the clinical notes that we make about them. In general, patients do not expect doctors to write notes in plain language.
They are not bothered by terms they do not understand and they feel very fortunate to have a window into more information about their own health.
Even so, it is worth keeping in mind a key practical aspect: let’s make our clinical notes with the understanding that they can become a communication with our patient as well as a legal instrument.
Therefore there are certain practices that may be of interest:
Let’s avoid complicated jargon or abbreviations whenever we can, especially those that patients can easily misinterpret. Let’s leave the more technical data for our talks or scientific articles.
Let us incorporate the interpretation of laboratory results or imaging studies into our notes to give patients a complete picture of our assessment.
Let’s include a detailed treatment plan for your patients with links to material of interest.
Let’s keep the sensitive issues in mind and be correct in the way we describe it in the medical record.
Except for obvious exceptions, do not write in the clinical notes something that we are not willing to transmit to the patient face to face.
If it is something difficult to discuss with the patient, perhaps this is a sign that it is precisely something that we have to face.
What if patients disagree with what I wrote and want the note changed?
Changing a clinical note is always at our discretion. If we think the change improves the grade, we can simply document it as an appendix or use our center’s usual mechanism to edit or correct a grade.
In highly experienced multi-center studies, patients rarely request that clinicians change clinical notes. In general, institutions report little or no increase in requests for changes to the record after patients have access to their notes.
Recent research suggests that inviting patients, families, and caregivers to review notes can help them identify clinically important inaccuracies, address confusion about the care plan, or find flaws in a follow-up that, once corrected, improves safety.
If patients access their clinical notes, will we receive more complaints?
According to this Kachalia study, transparent communication is the best policy. Even on such a sensitive subject as medical error reporting, open and honest communication can dramatically decrease the number of lawsuits.
The most important factor when it comes to responsibility is trust. Research clearly shows that access to clinical notes builds trust, even when errors are noted and corrected.
Therefore, it seems logical that the relationship between transparency and legal problems is inversely proportional, the more frank we are, the fewer demands there will be.
For all this, we have to clearly consider that the concept of protecting the clinical notes from our patients, the way Gollum protects his treasure, no longer applies in the transparent society in which we live.
We have to adapt our practice to this reality and perhaps also take advantage of doing so.