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Patients now have access to doctor's visit notes: A guide to what's inside

What does your doctor really think about your condition and health concerns? For more than a year now, patients have been able to access and read the observations doctors write down about them during a visit.

The clinical notes can come with surprises. Patients may be amused to find out they’re described by their physician as “well-nourished,” “well-groomed,” “pleasant” or “normal-looking.”

“’He is not ill-appearing or toxic-appearing.’ That’s the best review I’ve ever received,” one man wrote on Twitter after reading his doctor’s notes.

But patients may also be taken aback by comments referring to them as “obese” or mentioning their marijuana use. One woman was shocked when she saw her doctor wrote down that she “seemed overly dramatic,” she complained on Reddit .

As of April 2021, healthcare providers must give patients access to all of the health information in their electronic medical records as part of the 21st Century Cures Act . That includes your doctor’s written comments about your physical condition during a visit, along with any symptoms and what the treatment should be.

The rules don’t apply to psychotherapy notes made during counseling sessions or when doctors believe a patient would harm another person or themselves after reading the information, according to OpenNotes , a non-profit organization based at Beth Israel Deaconess Medical Center in Boston that advocates for greater transparency in healthcare.

Doctors have been both supportive and cautious of the movement. In a 2020 survey of 1,628 clinicians, 74% agreed note sharing was a good idea.

“It does give the patient a lot more ownership of their medical condition because they can see what we’re thinking about, they understand our thought processes a little bit more, and they can see what the options are,” Dr. Sterling Ransone, Jr., a family physician in Deltaville, Virginia, and chair of the American Academy of Family Physicians, told TODAY.

But knowing that patients can now read his notes, Ransone finds he self-censors himself to avoid sounding critical or judgmental of a patient.

“It’s difficult because sometimes you have to leave a note to yourself what your concerns are, but they can cause anxiety with the patient,” he noted. “I can say that it really has changed the way that a lot of physicians write their notes.”

That means more accessible language, less jargon and more caution with certain terms that might offend or upset a patient.

Ransone no longer uses the abbreviation “SOB,” which stands for “short of breath” and instead writes out the full term in his notes. Same with “FU,” which stands for “follow up.”

The American Academy of Family Physicians has also urged doctors to write “patient could not recall” instead of describing them as a “poor historian;” “patient declines” instead of “patient refuses;” and “patient is not doing X” instead of describing them as “non-compliant.”

A guide to your doctor’s note:

The medical note has traditionally included four parts, Ransone said: The subjective findings, or what a patient said they were concerned about; the objective findings, or what the doctor actually observed during the visit; the physician’s assessment after evaluating the patient and the treatment plan.

Doctors are used to jotting down any observations that can offer clues to what’s going on. So writing down that a patient “seemed overly dramatic” can mean the person’s complaint wasn’t consistent with the degree of their symptoms and something else might be the reason for their visit that day, he noted.

Here are other descriptions patients may find in their doctor’s notes:

Well-groomed or pleasant: This can indicate mental status. “If someone comes in and they’re somewhat disheveled, it leads you to wonder why and what do I need to look into?” Ransone said. “Pleasant” means the patient was communicative and responded to social cues, he noted. Patients who are upset or sleepy could have a substance abuse disorder or another reason why they’re having trouble interacting.

Well-developed or well-nourished: “A lot of times when people look at open notes and they’ll say, ‘Well, of course I am. What does this mean?’” Ransone said. “It just means that we checked in our mental checklist… (that) those aren’t things that we need to worry about.” If a person isn’t well-nourished, it might mean they don’t have access to food or their teeth might be in such bad condition that they can’t chew and get nutrition.

Unremarkable: This is a good thing. “Unremarkable is exactly what you want to be when you see a physician,” Ransone said. “I joke with my patients all the time: You want to be the most boring patient that I’ve seen today, because that means we haven’t seen anything that is abnormal that we need to chase down.”

Obese : To a physician, the term means the patient is of a certain weight for their height and frame, which comes with a certain constellation of medical concerns, Ransone said. “There’s a stigma to obesity in society and a lot of patients really don’t want to have that on their charts… but it’s a very important piece of the puzzle for me as I’m trying to help a patient get healthier,” he noted.

Substance use: This isn’t necessarily bad. Doctors will note a patient has an occasional glass of wine, for example, to give them an idea of the person’s alcohol consumption habits. “The way that our society looks at, say, marijuana use has changed a lot over the years, but a lot of people don’t want that included in the medical record,” Ransone said. “I’d like to know if someone is smoking weed because it could affect the medications that I should give them for their health condition.”

Other health observations patients frequently don’t want on their chart include mental health issues such as depression, anxiety or bipolar disorder, he noted.

Some patients have called Ransone to ask that he change something in their note because they see it as a pejorative or they disagree with his assessment, but that doesn’t mean he’s wrong, the doctor noted.

One guide for physicians suggested telling the patient: “I’m sorry you disagree with my assessment. While I can’t change my medical opinion, if you’d like I can add that you disagree with it.”

Patients pointing out factual errors — such as noticing the note referenced a problem in the right knee rather than the left — is a completely different issue. If there's anything inaccurate in your chart, bring it to your doctor's attention.

In fact, patients who read their doctor’s notes may play an important role in finding errors in their records, a 2020 study published in JAMA found.

Ransone encouraged patients who are reading their doctor’s notes to keep the lines of communication with their physician open.

“Don’t necessarily assume the worst when they read things. Realize that a lot of the things that they read are open to interpretation,” he advised.

A. Pawlowski is a TODAY health reporter focusing on health news and features. Previously, she was a writer, producer and editor at CNN.

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Patient Access To Medical Records Is Set To Become Mandatory

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Key Takeaways

• Starting in April 2021, the United States' government will require health organizations to share medical records with patients electronically, free of charge.
• Once the mandate goes into effect, patients will be able to see doctors' notes and other information in their electronic medical record.

It’s soon going to be easier to read your doctor's notes from your last visit thanks to a measure to improve patient record transparency. Starting in April 2021, all medical practices will be required to provide patients free access to their medical records. The concept of sharing medical notes is known as OpenNotes.

Under the  21st Century Cures Act , consumers will be able to read notes that recap a visit to the doctor’s office as well as look at test results electronically.

In the past, accessing your doctor's notes could require long wait times and fees. The Health Insurance Portability and Accountability Act (HIPAA) made it legal to review medical records, but it didn't guarantee electronic access.

More than 250 healthcare organizations in the U.S. (including multiple locations within a single system) are already sharing notes with patients digitally.

What Is OpenNotes?

With OpenNotes , doctors share their notes with patients through electronic health records (EHR). Practices and hospitals use various kinds of software for EHRs, such as MyChart. Once the mandated medical transparency measure goes into effect, patients will be able to log in and see their notes.

The mandate was supposed to begin on November 2, 2020, but in the midst of the COVID-19 pandemic, the deadline was extended to April 5, 2021.

Doctor’s notes will include consultations, imaging and lab findings, a patient's medical history, physical exam findings, and documentation from procedures.

Cait DesRoches , executive director of OpenNotes (a group advocating patient note access), explains that patients will have two ways to get their notes. Either the organization will put the notes on the portal automatically or a patient can request that notes be added to the portal.

“The notes are full of great information for patients,” DesRoches tells Verywell. Viewing the notes can help patients recall what they discussed with their doctors during a visit as well as remind them of what they’re supposed to do after an appointment.

“My hope is that organizations will implement this in a really robust way,” DesRoches says. “That’s when the health system will get to the place where they’re seeing the benefits.

What This Means For You

Being able to see notes in an electronic portal also provides patients with the opportunity to ensure that their medical records are accurate. Before the mandate goes into effect in April 2021, talk to your doctor about how you will be able to access your medical record.

Downsides of Data Sharing

The ability to view documentation from medical care sounds like a great opportunity for patients, but some worry that it could create confusion. For physicians, there's also the potential for an increased workload, as they might need to respond to questions that arise when patients see—and question—what's in their notes.

UC San Diego Health launched a pilot program using OpenNotes for primary care patients in 2018. Marlene Millen, MD , a professor and doctor in the UC San Diego Health , told MedicalXpress that she did not see an increase in inquiries from patients when their notes were available.

What To Know About Doctors’ Notes

There are some cases when a doctor does not have to share medical notes with patients. These scenarios are different state by state, as privacy laws vary.

Doctors can withhold medical records if they think releasing the information will lead to physical harm, such as in the case of partner violence or child abuse.

Providers also do not have to share information regarding certain diagnoses that are considered protected, and psychotherapy documentation is not shared. However, other mental health services outside of talk therapy—such as talking to your primary care doctor about depression—are included in the notes.

Depending on the state you live in, DesRoches explains that parents can also view notes of their teen’s doctor visits. Parents might not have access when teens turn a certain age, based on the state. However, the rules don’t supersede state laws on privacy for adolescents.

Evaluating OpenNotes

OpenNotes.org reports that reading doctors' notes benefit patients in many ways and may lead to better health outcomes. According to OpenNotes, patients who are able to review their doctors' notes:

• Are more prepared for visits with their providers
• Can recall their care plans and adhere to treatment, including medication regimens
• Feel more in control of their care
• Have better relationships with their physicians
• Have a better understanding of their health and medical conditions
• Take better care of themselves

Several studies have assessed OpenNotes. A study published in the journal BMJ Open in September 2020 found that medical transparency is a right that is viewed favorably among people in different countries including Canada, Australia, Japan, Chile, Sweden, and the U.S.  

Another study published in the Journal of General Internal Medicine in July 2020 found that patients typically understand their doctor's notes and that the information in their record is accurate.   However, there were several notable disparities, and participants in the study had suggestions for improving the quality of access.

The researchers found that if patients didn’t understand a note or found inaccurate information in their notes, they had less confidence in their doctors.

According to a report in NEJM Catalyst, the ability to exchange information—including requesting information from patients before a visit—has been instrumental during the COVID-19 pandemic.   In addition to sharing notes with patients after a visit, doctors were able to send a pre-visit questionnaire to patients that enabled them to gather more detail before the visit.

“We suspect, for example, that patients and care partners may recall even less of telemedicine encounters than they do after face-to-face office visits," the authors noted. "As a result, they may turn more often to reading their OpenNotes online."

The researchers concluded that once there are patient- and clinician-friendly mechanisms in place for record-sharing, "inviting patients to contribute directly to their records will both support patient engagement and help clinician workflow.”

Advantages and Disadvantages

Wayne Brackin, CEO of  Kidz Medical Services , tells Verywell that it is “fair and reasonable” to expect patients would have access to doctors' notes. However, Brackin is concerned that doctors could “moderate their description in a manner that might affect care,” if they know that the patient or family will have access to records.

Wayne Brackin

To have a layperson, with a more limited vocabulary, or who has English as a second language, read the notes in isolation could lead to misunderstandings.

“This could be particularly sensitive with behavioral health issues," Brackin says, adding that a medical interpreter of sorts could help avoid misunderstandings during the initial record review. The language, abbreviations, and terminology in physician notes can be difficult for trained medical colleagues to interpret, let alone patients.

“To have a layperson, with a more limited vocabulary, or who has English as a second language, read the notes in isolation could lead to misunderstandings,” Brackin says.

Suzanne Leveille, RN, PhD, a professor of nursing at the University of Massachusetts and a member of the OpenNotes.org team tells Verywell that patients are generally enthusiastic about having online access to their office visit notes, but many providers initially expressed concerns that giving patients access to their notes could cause more worry than benefits.

"Our large surveys across health systems have not shown this to be the case. Very few patients report they became worried or confused from reading their notes," says Leveille, who also authored one of the OpenNotes' studies. "Overwhelmingly, patients report they benefit from note reading, for example, that it’s important for taking care of their health, feeling in control of their care, and remembering their plan of care."

While concerns about misunderstandings are not unwarranted, most patients report they are able to understand their notes, and that they have benefitted from viewing them. In cases where patients have been able to spot—and correct—mistakes, they feel not just more empowered, but safer.

"Open notes can improve patient safety," Leveille says. "About 20% of patients pick up errors in the notes and some report the errors to their providers."

Medical Xpress. More US patients to have easy, free access to doctor's notes .

Salmi L, Brudnicki S, Isono M, Riggare S, Rodriquez C, Schaper LK, et al. Six countries, six individuals: resourceful patients navigating medical records in Australia, Canada, Chile, Japan, Sweden and the USA . 2020. BMJ Open. doi:10.1136/bmjopen-2020-037016

Leveille SG, Fitzgerald P, Harcourt K, Dong Z, Bell S, O’Neill S, et al.  Patients evaluate visit notes written by their clinicians: a mixed methods investigation . 2020. J Gen Intern Med. doi:10.1007/s11606-020-06014-7

Kriegel, G, Bell S, Delbanco T, Walker J. Covid-19 as innovation accelerator: cogenerating telemedicine visit notes with patients . May 12, 2020. NEJM Catalyst. doi:10.1056/CAT.20.0154

By Kristen Fischer Kristen Fischer is a journalist who has covered health news for more than a decade. Her work has appeared in outlets like Healthline, Prevention, and HealthDay.

Doctor’s Note 101: What to Include and Why It Matters

• March 6, 2024
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When it comes to obtaining a doctor’s note, knowing what to include is key to ensuring its validity and usefulness. Here’s a breakdown of the essential elements of a doctor’s note  and why they matter:

1. Patient Information:

The doctor’s note should start with basic patient information, including the individual’s name, date of birth, and contact details. This information helps verify the note’s authenticity and ensures it is correctly attributed to the intended recipient.

2. Date of Visit:

Including the date of the doctor’s visit provides context and establishes the timeframe for the medical assessment. This information helps validate the note’s relevance and confirms that it was issued within an appropriate timeframe.

3. Healthcare Provider Details:

The doctor’s note should clearly state the healthcare provider’s name, credentials, and contact information. This ensures that the note is issued by a licensed medical professional and provides recipients with the means to verify its authenticity if necessary.

4. Diagnosis and Medical Condition:

A crucial component of the doctor’s note is the diagnosis  or description of the medical condition for which it was issued. This information helps school or workplace authorities understand the nature of the illness and determine appropriate accommodations or allowances.

5. Treatment Plan or Recommendations:

In addition to the diagnosis, the doctor’s note may include details of the treatment plan or recommendations provided to the patient. This may involve prescribed medications, suggested rest periods, or other relevant instructions for managing the medical condition.

6. Duration of Excuse:

The doctor’s note should specify the duration for which the individual is excused from school or work activities due to their medical condition. This helps establish clear expectations and ensures that the individual receives the necessary time off to recover fully.

Get a reliable doctor’s note online

A well-crafted doctor’s note includes essential information such as patient details, date of visit, healthcare provider information, diagnosis, treatment plan, and duration of excuse. By including these elements, the note becomes a valuable tool for communicating medical needs and facilitating appropriate accommodations.

Ready to obtain a comprehensive doctor’s note for your specific needs? Visit My Dr’s Note  for assistance in obtaining valid and effective medical documentation. If you need an online doctor’s excuse for work or school, we’ve got your back.

Learn more here !

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Inviting patients to review your visit notes is a promising change in practice. Here's how to get started .

HANNAH CHIMOWITZ, AND LEONOR FERNANDEZ, MD

Fam Pract Manag. 2016;23(6):10-13

Author disclosures: no relevant financial affiliations disclosed.

Health care benefits from productive patient engagement, and patient engagement benefits from fully transparent health care. However, patients have long lacked ready access to their health information. Twenty years ago, HIPAA granted virtually all patients the right to review their medical records, but logistical barriers keep most patients from regularly doing so. 1 – 2

With the widespread adoption of electronic health records (EHRs) and the advent of secure patient portals, patients are now increasingly able to exchange emails with their physicians and review laboratory and radiographic results and medication lists online. But visit notes, which tell the patient's story and weave together disparate issues, have remained largely hidden from patients.

OpenNotes is a national initiative whereby physicians invite patients to review their visit notes. It is not a product or service for sale; it is a movement to allow patients greater access to their health information. In what follows, we outline early experiences, explain how to implement shared notes, point out challenges and unanswered questions, and attempt to demonstrate that this practice holds considerable potential for improving the value and safety of care.

Early experiences

The initial OpenNotes demonstration and evaluation effort in 2010 involved 20,000 patients and more than 100 primary care physicians at three diverse institutions: Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in rural Pennsylvania, and Harborview Medical Center in inner-city Seattle. The findings after a year of intervention were striking. (See “ What the research shows .”) Eight of 10 patients chose to read at least one of their visit notes, and three of four reported clinically important benefits, including recalling visit details more completely, understanding their medical conditions better, taking better care of themselves, and feeling more in control of their care. 3 Few patients were confused, frightened, or offended after reading their notes, and many shared their notes with family members and caregivers. Whether or not they chose to read their notes, 99 percent of patients wanted the practice to continue after the year-long study, and almost 90 percent reported that the availability of shared notes would affect their future choice of a practice or clinician. 3

Clinicians reported that patients who received shared notes seemed to feel more in control of their care, coming to their visits better prepared and asking well-informed questions. Moreover, shared notes enhanced trust and the doctor-patient relationship. More than one third of patients who read at least one note during the OpenNotes trial reported feeling better about their doctor, and shared visit notes had overall positive effects on physician perceptions of patient trust and satisfaction. 4

Clinicians also reported that shared notes reinforced their discussions in the office, helping patients remember next steps and adhere to treatment plans. A separate study reinforced this, finding that patients who viewed shared notes are more likely to refill their blood pressure medication than those without access to their visit notes. 5

Shared notes also benefitted patient safety and quality of care by offering patients and caregivers opportunities to correct errors or clarify misunderstandings. Among the 7 percent of patients in the OpenNotes trial who reported contacting their doctor's office about their note, about one third found an error in their note, and 85 percent of these patients were satisfied with the resolution. 4 In addition, caregivers expressed that shared access to visit notes helped them to participate more actively in patient care, including interpreting health information, advocating for quality care, and managing the patient's health behaviors and medical care. 6

Contrary to primary care physicians' expectations prior to the study, the process of sharing visit notes required little change in their workflow. Eight percent reported taking more time to address patients' questions outside of visits, and 21 percent reported taking more time to write notes.

Although roughly a quarter of the doctors who participated said they would prefer not to continue the practice at the end of the voluntary year-long intervention, each decided to continue. Today, each of the three sites is deploying shared notes widely in their primary care and specialty practices, about 10 million Americans are being invited to review their visit notes, and we know of fewer than 10 doctors who have discontinued the practice.

WHAT THE RESEARCH SHOWS

Patients report that by reading visit notes, they :

Remember better what was discussed during visits,

Feel more in control of their care,

Are more likely to take medications as prescribed,

Can share notes with their caregivers and better equip them.

Doctors and other clinicians report that by sharing visit notes, they :

Promote patient communication and education,

Can help patients be better prepared for visits,

Can help patients' family and caregivers optimize care,

Can meet patients' desire for access to their notes.

Source: Delbanco T, Walker J, Bell SK, et al. Inviting patients to read their doctors' notes: a quasi-experimental study and a look ahead [published correction appears in Ann Intern Med . 2015;162(7):532]. Ann Intern Med . 2012;157(7):461–470.

How to implement shared notes

Although sharing visit notes is a radical change in practice, it can be relatively easy to adopt. Physicians should consider the following issues.

Documentation . Most providers participating in the OpenNotes pilot project reported they did not need to change the way they wrote their notes. However, a minority of doctors reported modifying the way they documented potentially sensitive topics, such as mental health, obesity, substance abuse, sexual history, or elder, child, or spousal abuse. We recommend physicians take simple steps to improve their notes such as avoiding patient labels (e.g., “non-compliant”), medical jargon, and confusing abbreviations. (See “ Tips for writing transparent notes .”)

The practice of sharing notes may gradually influence some of the language, tone, and terms clinicians use in documenting patient care, 7 but this could be a positive development as medicine becomes more collaborative.

TIPS FOR WRITING TRANSPARENT NOTES

Be transparent . Your communication in the office should reflect what you plan to put in the note.

Minimize jargon and abbreviations , especially any that patients might easily misinterpret.

Briefly define or simplify medical terms , such as short of breath, rather than SOB or dyspneic.

Highlight the patient's strengths and achievements in addition to his or her symptoms.

Describe behaviors rather than labeling the patient or making judgments. For example, consider these alternatives:

“Patient could not recall” instead of “Poor historian,”

“Patient is not doing X” instead of “Non-compliant,”

“Patient prefers not to” or “Patient declines” instead of “Patient refuses.”

Technology . OpenNotes is not a software program or technology product. It is simply an initiative to encourage physicians to share their notes. It does not depend on health information technology. For example, physicians can share their visit notes manually by printing a copy and handing it to the patient at the end of the visit, although EHRs and patient portals facilitate the practice markedly. Not all EHR vendors offer patient portals, and among those that do, clinical notes have generally remained hidden by default, although we do know of one major vendor that is now offering full transparency by default on their new installations. As the call for full transparency spreads, we expect more vendors to follow suit.

Early OpenNotes implementers have learned the importance of setting up automatic electronic alerts to notify patients via email that a new note is available for viewing in the patient portal. Patients are much more likely to look at visit notes when reminded electronically. In the year following the OpenNotes trial, one institution discontinued electronic alerts, while another institution continued to use them. Patients who received reminders continued to view their notes consistently, while the reading rates at the site without reminders dropped nearly 50 percent. 8

Implementation . As more institutions begin to offer shared notes, we are seeing many different approaches to implementation. Some institutions and health care systems begin by making clinical notes open throughout all practices, while others begin with pilot programs in a few departments. Some institutions allow clinicians to opt in, but most take an opt-out approach, making shared notes the default. Nearly all institutions allow clinicians to “hide” selected notes from patients, and patients are usually not offered access to notes written before the adoption of shared notes. Regardless of how a group chooses to implement shared notes, the change should be communicated in a timely and clear way to clinicians, staff, and patients so that everyone feels prepared. This may include compiling a set of frequently asked questions and answers that address common concerns among clinicians, equipping staff with materials that describe the change for patients, and sharing the research with clinicians and staff to show that shared notes benefit patients with minimal impact on clinician work life. (For more information and resources for getting started, visit the OpenNotes online toolkit .)

Physician buy-in . Practice change is difficult and often requires a vocal “champion” – a respected leader with strong commitment to the change. Many physicians already feel overworked and stressed by changes in health care and view their EHR as onerous, perhaps rightly so. They may assume that shared notes will add to their daily workload, worry about potential harm to patients, 9 or fear that patients will question the accuracy of their medical histories or become more aware of errors or instances of suboptimal quality of care. Having a champion who can serve as a resource for these physicians, addressing their questions and concerns, is invaluable.

Cautions . We have seen few negative consequences of shared notes, but we encourage groups to consider potential pitfalls and challenges, including these:

As doctors direct their notes increasingly toward patients and families, will some oversimplify notes in a way that interferes with communication with their fellow clinicians?

As patients become more familiar with the content of medical records, will some withhold important information from their clinicians?

How should situations of suspected abuse of a patient be documented?

How can adolescents gain access to their records in a way that fosters their engagement without interfering with the rights of parents?

How can records be meaningful and accessible to diverse populations, including those who speak another language or have limited health literacy?

These important questions need continued attention and research as we move forward.

Small change, big results

Shared notes enhance communication and engagement among patients, clinicians, and family members and can be an important facilitator of shared decision making. Patients report valuable clinical benefits, including improved adherence to their medications and treatment plans. Patients want transparency, and those who have experienced shared notes believe the practice should continue. Most providers who share notes want to continue the practice as well and do not report an increase in time spent writing notes.

With greater transparency, quality of care and patient safety may increase, along with health care value. Much remains to be learned about the best way to make patients' health information meaningful and accessible to them. But overall, we believe that this intervention, which is simple to execute yet quite complex in its ramifications, will bring many transformative benefits to health care.

Fioriglio G, Szolovits P. Copy fees and patients' rights to obtain a copy of their medical records: from law to reality. AMIA Annu Symp Proc . 2005;:251-255.

Shute N. Patients want to read doctors' notes but many doctors balk. NPR. Dec. 21, 2011. http://n.pr/2dFaRMS . Accessed Oct. 3, 2016.

Delbanco T, Walker J, Bell SK, et al.; Inviting patients to read their doctors' notes: a quasi-experimental study and a look ahead [published correction appears in Ann Intern Med . 2015;162(7):532]. Ann Intern Med . 2012;157(7):461-470.

Bell SK, Mejilla R, Anselmo M, et al.; When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient-doctor relationship. BMJ Qual Saf . 2016;.

Wright E, Darer J, Tang X, et al.; Sharing physician notes through an electronic portal is associated with improved medication adherence: quasi-experimental study. Med Internet Res . 2015;17(10):e226.

Tieu L, Sarkar U, Schillinger D, et al.; Barriers and facilitators to online portal use among patients and caregivers in a safety net health care system: a qualitative study. J Med Internet Res . 2015;17(12):e275.

Klein JW, Jackson SL, Bell SK, et al.; Your patient is now reading your note: opportunities, problems, and prospects. Am J Medicine . 2016;129(10):1018-1021.

Mafi J, Mejilla R, Feldman H, et al.; Patients learning to read their doctors' notes: the importance of reminders. J Am Med Inform Assoc . 2016;23(5):951-955.

Walker J, Leveille SG, Ngo L, et al.; Inviting patients to read their doctors' notes: patients and doctors look ahead: patient and physician surveys. Ann Intern Med . 2011;155(12):811-819.

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Do You Really Want to Read What Your Doctor Writes About You?

You’re now allowed to see everything physicians say about you in their notes. It’s complicated.

You may not be aware of this, but you can read everything that your doctor writes about you. Go to your patient portal online, click around until you land on notes from your past visits, and read away. This is a recent development, and a big one. Previously, you always had the right to request your medical record from your care providers—an often expensive and sometimes fruitless process—but in April 2021, a new federal rule went into effect , mandating that patients have the legal right to freely and electronically access most kinds of notes written about them by their doctors.

If you’ve never heard of “ open notes ,” as this new law is informally called, you’re not the only one. Doctors say that the majority of their patients have no clue. (This certainly has been the case for all of the friends and family I’ve asked.) If you do know about the law, you likely know a lot about it. That’s typically because you’re a doctor—one who now has to navigate a new era of transparency in medicine—or you’re someone who knows a doctor, or you’re a patient who has become intricately familiar with this country’s health system for one reason or another.

When open notes went into effect, the change was lauded by advocates as part of a greater push toward patient autonomy and away from medical gatekeeping. Previously, hospitals could charge up to hundreds of dollars to release records, if they released them at all. Many doctors, meanwhile, have been far from thrilled about open notes. They’ve argued that this rule will introduce more challenges than benefits for both patients and themselves. At worst, some have fretted, the law will damage people’s trust of doctors and make everyone’s lives worse.

A year and a half in, however, open notes don’t seem to have done too much of anything. So far, they have neither revolutionized patient care nor sunk America’s medical establishment. Instead, doctors say, open notes have barely shifted the clinical experience at all. Few individual practitioners have been advertising the change, and few patients are seeking it out on their own. We’ve been left with a partially implemented system and a big unresolved question: How much, really, should you want to read what your doctor is writing about you?

The debate about open notes can be boiled down to a matter of practicality versus idealism. You’d be hard-pressed to find anyone, doctor or otherwise, who argues against transparency for patients in principle . At the same time, few people I spoke with for this article believe that the new rule has been put in place all that smoothly. For care providers, the primary concern has been the trouble that can come with writing notes for a new audience. Notes, generally scribbled in shorthand incomprehensible to the unknowing eye, have traditionally served doctors, and doctors alone. They allowed physicians to stay up to date on their patients and share information with colleagues for input on cases.

Some doctors told me they worry that open notes could result in distress for patients who read something they don’t understand, and that highly technical language could make something sound worse than it is. Oncology, for instance, can involve an onslaught of potentially concerning terminology . (Psychotherapy notes are exempt from the new rule.) Other doctors fear that valuable information can be lost if they go too far in de-jargonizing notes to make them patient-friendly. Or that de-jargonizing notes is simply unfeasible. “Let’s say you came to me with pain and pointed to your mid-clavicular line. I’d just put ‘MCL,’” says Aldo Peixoto, a nephrologist at Yale. “But if I were writing for you to understand, I’d have to say ‘pain on the top-right portion of her abdomen in the line that runs from the middle of her clavicle,’ and so on. Rather than writing four lines of prose, I could’ve used literally three letters.”

If that sounds quibbling, consider the trade-offs. Less time for doctors can translate into less time for patients. Many clinicians already write notes well into the evening. Certainly, the pandemic hasn’t helped . Some doctors told me that if they find themselves in a dilemma of either writing notes in less-efficient, plain language or fielding worried patient calls and messages, exhausted practitioners will face yet another burden. And then there’s the matter of trust. Jack Resneck, the president of the American Medical Association, the nation’s largest professional group of doctors and medical students, told me that doctors can need time and space with patients to get them to open up and be receptive to guidance through difficult situations. If these patients were to see notes too soon, Resneck said, they might “immediately flee and not come back to see you.”

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As doctors have spent more time dealing with open notes, many have eased off their strongest objections. Some, including Resneck and the AMA, have warmed up to the new rule as certain exceptions have been granted, such as allowing doctors whose patients have parents or partners with access to their notes to omit certain details from their write-ups for privacy reasons. Other physicians seem to be coming to a somewhat awkward realization: On a practical level, many concerns about how this change affects patients are irrelevant, because most patients don’t yet know they have instant access to their notes in the first place. Every doctor I spoke with for this story told me that their patients were largely unaware. Many doctors and hospitals are not going out of their way to inform people about the new rule, so unless patients are particularly on top of shifting rules within our convoluted health-care system, they’re unlikely to encounter the notes on their own. Kerin Adelson, an oncologist at Yale, admitted she didn’t know how to find notes in her own patient portal. She spent several minutes with me on the phone fumbling through different tabs to locate them.

Fans of open notes are frustrated that there is not a greater push for awareness. Even acknowledging that the new system has its shortcomings, many argue that the only way to make things better is to get people invested in the access they’ve recently been granted. Lydia Dugdale, a primary-care doctor at Columbia University, worries about ensuring equity. “Things like socioeconomic status, education, literacy: All of those issues affect the degree to which any given patient is going to want to read and correct and interrogate his or her health record,” she told me. Tom Delbanco, a Harvard doctor and one of the co-founders of OpenNotes, an initiative that spearheaded the push for access to doctors’ notes in the U.S., believes that the effort required to refrain from using “bad words” in notes is minor, and that it shouldn’t make any significant demands on clinicians’ schedules. Doctors who are now taking more time to write notes because of the change, he told me, “probably ought to because they’ve been writing lousy notes.”

Open notes can be valuable for people with chronic conditions and their caregivers, who need to stay in the know. Liz Salmi, the communications and patient-initiatives director at OpenNotes, told me about pulling her full medical record eight years into dealing with brain cancer, before notes were easily and freely available. The document was 4,839 pages. To get a PDF, she said, she had to pay $15 for each DVD it was uploaded to, and her records spanned multiple discs. But the information was worth it: Having access to the record gave Salmi a way to remember all of the crucial bits of information she’d gotten piecemeal from various doctors.

The fact that many people have no idea open notes exist doesn’t change the deeply personal questions at stake in the debate about whether the notes do more good or harm—questions that everyone must confront in one way or another in dealing with America’s medical system, whether or not they fully realize it. How much information do you truly want about your health, and how much do you trust your doctor to deliver it to you? What is a doctor’s role in informing people about their health?

Read: Following your gut isn’t the right way to go

Open notes are only part of this conversation. The new law also requires that test results be made immediately available to patients, meaning that patients might see their health information before their physician does. Although this is fine for the majority of tests, problems arise when results are harbingers of more complex, or just bad, news. Doctors I spoke with shared that some of their patients have suffered trauma from learning about their melanoma or pancreatic cancer or their child’s leukemia from an electronic message in the middle of the night, with no doctor to call and talk through the seriousness of that result with. This was the case for Tara Daniels, a digital-marketing consultant who lives near Boston. She’s had leukemia three times, and learned about the third via a late-night notification from her patient portal. Daniels appreciates the convenience of open notes, which help her keep track of her interactions with various doctors. But, she told me, when it comes to instant results, “I still hold a lot of resentment over the fact that I found out from test results, that I had to figure it out myself, before my doctor was able to tell me.”

As Americans continue to age, get sick, and navigate the health-care system, many of us may become more invested in the idea of open notes. Until they play a more widespread role in people’s lives, however, the most pressing question about whether you truly want instant access to all your medical information might be how it affects your doctor’s life. Many physicians have come around to open notes, or at least have realized that allowing patients to see what has been written about them is not always a huge bother. But the bigger question of just how quickly patients should be able to access medical information, and how soon doctors should be available to help patients process it, continues to plague physicians. The advent of immediate data sharing “has been a major problem in terms of physician quality of life, and that’s eroded across the board,” Peixoto told me. “Doctors don’t want to be connected all the time. They actually have their lives.”

Where we have landed, then, is an in-between. Patients can read their doctor’s notes and view test results at any hour of the day, but we can access our providers only at certain times. There is likely room for refinement. Allowing a patient to select whether they receive test results from their physician or their portal, or see notes only after their doctor has had the opportunity to walk them through the terminology used, for instance, could make all the difference, some doctors told me. For now, it’s worth asking yourself whether you want to access your patient portal alone, or want to wait until you can get your doctor on the line.

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Doctor's note for work or school

What is a doctor’s note.

A doctor’s note, sometimes called a medical excuse, medical leave note, or sick note, is a document written by a doctor or other qualified medical professional to explain absence from work due to a medical condition or to provide proof that you saw a medical professional.

A doctor’s note could be used to excuse an employee from work for a specific amount of time, or it could be used to explain why a student was absent from school.

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When Should You Get a Doctor’s Note for Work?

If you are unable to work due to an illness or injury, then you should get a doctor’s note from a certified medical professional.

There are many potential reasons to get a doctor’s note for work such as:

• If you are experiencing any symptoms that could be associated with the coronavirus or need to be and need to provide your employer with proof of illness.
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• You have suffered an injury and need to take some time off for healing.
• You are pregnant and need certain accommodations.
• You are experiencing a mental health disorder and require extra support.
• When you see a doctor during your work hours, you may also need to provide a doctor’s note.
• If you can’t perform certain duties due to a medical condition.

Overall the actual need to get a doctor’s note for work will depend on your specific situation and may vary from one employer to the next also it will depend on your state and labor laws.

If you think you might need a doctor’s note for work consult with your company’s HR department or speak with a qualified medical professional about your situation.

When Should You Get a Doctor’s Note for School?

If you are too sick to attend school, a doctor’s note can provide proof of a medical condition and help explain why you were absent. Most schools require that students submit a doctor’s note in order to be excused from class or receive an extended due date for any missed assignments.

In some cases, such as if the student is taking an extended leave of absence from school, a doctor’s note may also be required to get the necessary accommodations.

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To get a doctor’s note you should make an appointment with your healthcare provider and explain why you need the note.

It is important to provide as much detail as possible when discussing your situation; this will help the doctor ensure that their assessment of the situation is accurate and complete.

Depending on the circumstances, your doctor may be able to provide you with a doctor’s note. This document can serve as proof of your absence and allow you to take time off without having to worry about repercussions from employers or other authority figures. 

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If you require a doctor’s note for a medical excuse, the easiest and most convenient way to get it is from an online doctor . This can be incredibly useful if you need proof of an illness or injury but can’t make it into the doctor’s office.

To get an online doctor’s note from DrHouse, you simply need to set up an account, download our telehealth app and start an on-demand visit with one of our clinicians.

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Overall, getting a doctor’s note online is the most convenient option available if you need a sick note for work or school. It can save you time, money, and effort while also ensuring that you receive quality care from experienced healthcare professionals.

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A doctor’s note typically contains the following information:

• Your name and date of birth.
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