Open Medical Records: A Question of SafetyAugust 3, 2010
By Christine Moffa, MS, RN, AJN clinical editor
We’ve all watched our health care provider writing or typing while we answered questions or described our symptoms. Before becoming a nurse I used to wonder what they were putting in my chart and if they got it right. And now that I am a nurse I can’t believe how often a medical assistant or nurse will take my vital signs and write them down without telling me what they are. How can it be possible that adults are kept from knowing their own or their children’s health information? Back when I worked on a pediatric floor my colleagues gasped in shock when I allowed a parent of one of my patients to look at his child’s chart. And I actually let them make me feel like I had done something wrong!
Last week this issue was the topic of a column by Dr. Pauline W. Chen in the New York Times, where two related blog posts (here and here) also received much reader commentary. The sudden flurry of interest in the subject was occasioned by an article published in the Annals of Internal Medicine detailing the preliminary findings of a study following a national project called OpenNotes, funded by the Robert Wood Johnson Foundation, in which “more than 100 primary care physicians and 25,000 of their patients will have access to personal medical records online for a 12-month period beginning in summer 2010.” Readers’ comments ranged from one extreme to the other, such as the following:
- “The records are the doctor’s; the doctor creates the record. Just as I would create a file on a client, the intellectual property is mine, I can have control.”
- “As a healthcare consumer, I pay a lot of money out-of-pocket to healthcare providers for the services they render me. I am fully entitled to the documentation produced as part of this business transaction.”
Patients finding errors. Last year, as part of our ongoing “Putting Patients First” series, AJN published an article, by Susan Frampton of the Planetree organization, about Griffin Hospital in Derby, CT (there’s also a series of free Webinars, the next of which is on September 21). At this facility patients can view their records either alone or during conferences with their health care providers. In addition to increasing patient satisfaction, this openness about medical records may also improve safety. According to the article,
“At hospitals with open medical records policies, patients viewing their own medical records have identified numerous errors (for example, name, address, allergies, medications, and historical data); a recent study comparing data obtained from postdischarge patient interviews and medical records indicated that patients can help ensure their medical records’ accuracy regarding adverse events, and that the safety of the care provided may be improved when patients can view their records and correct mistakes and omissions.”
What happens at your facility when a patient asks to see their records?