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). ...
Blease C, Walker J, DesRoches CM, et al. New U.S. law mandates access to clinical notes: implications for patients and clinicians. Ann Intern Med. 2021;174:101-2. doi:10.7326/M20-5370 LinkGoogle Scholar
- 2. Sweeney Anthony E. The Cures Act Final Rule: interoperability-focused policies that empower patients and support providers. HealthITBuzz Blog. 9 March 2020. Accessed at www.healthit.gov/buzz-blog/21st-century-cures-act/the-cures-final-rule on 1 October 2020. Google Scholar
Gantzer HE, Block BL, Hobgood LC, et al. Restoring the story and creating a valuable clinical note [Editorial]. Ann Intern Med. 2020;173:380-382. doi:10.7326/M20-0934 LinkGoogle Scholar
Delbanco T, Walker J, Bell SK, et al. Inviting patients to read their doctors' notes: a quasi-experimental study and a look ahead. Ann Intern Med. 2012;157:461-70. doi:10.7326/0003-4819-157-7-201210020-00002 LinkGoogle Scholar
Author, Article, and Disclosure Information
Heather E. Gantzer,
Park Nicollet Clinic, St. Louis Park, Minnesota (H.E.G.)
Disclosures: The author has disclosed no conflicts of interest. The form can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-6632.
Corresponding Author: Heather E. Gantzer, MD, 3800 Park Nicollet Boulevard, St. Louis Park, MN 55416; e-mail, hgantzer@mac.
This article was published at Annals.org on 13 October 2020.