Open Medical Records: A Question of Safety

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 […]