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Open Medical Records: A Question of Safety

August 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?

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3 comments

  1. Late deafened adult here who came away from a 7 day stay in a hospital in much worse condition. I am wondering why no one made any effort to communicate with me – I do not sign. I had to demand my medical records(six times in very clear language – it’s the law in my state) to find out what happened to me as I could not walk after the first day, had burning pain at IV site, then had a lot of trouble breathing. I now know I had an adverse reaction to a drug they used. I was never consulted about what drugs to use or not use – asked if allergic – NKOD. No information was offered. I had one night nurse hovering over me almost all night four days in, they were acting perplexed and anixous, if I had not been so drugged up, I would have registered some doubts. I did tell nurses things but was always told, your doctor knows. Reading my records told me none of this information I pointed out was recorded.

    I have been looking for feedback on how as a deaf person who can speak clearly but does not sound very good, can definately read written word, how do I deal with medical personnel who just don’t want to deal with my deafness. I am the only person who knows how I feel, what I want and when I ask questions, I want answers. When I left the hospital I could not walk, do anything that I usually did up to time I entered hospital. I suffered excruciating pains all over my body that I had never felt before and knew it was not from recovery of pneumonia. Called hospital and doctor – said to go to another doctor. The doctor who treated me in hospital had gone to other employment. I am now crippled, have lost the use of my left arm and visiting more doctors how do not have a clue. Really scary situation. I hadve had excellent doctors care up to this point in my life. I have been really healthy the late few years(10) since I became deaf…and needed no care. What happened?

    If this is out ofline, please feel free to delete. I use computer online for communication and am only seeking information.

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  2. Patients should have open access to their records and should be encouraged to review them for accuracy during each visit. This would truly enhance patient care and satisfaction as well as promote great safety, such as better medication reconciliation. If patients felt as if they had more control over their care, they may actually take better care of themselves as well. It’s worth a try!

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  3. When charting on a patient, especially on admission, I frequently use the repeat and verify method I would use with their physician. This eliminates confusion and lets them know I am listening. It also builds trust and clarifies information given by an ill patient or exhausted family member.

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