FAQ about OpenNotes for practice staff
This handout answers commonly asked questions about OpenNotes. Review the highlighted sections and add in pertinent details about your practice. Then share and discuss the document with care team members and practice staff.
What is OpenNotes?
OpenNotes is a way to give patients access to the health care notes that doctors, nurses and other clinicians write after a clinical appointment or discussion. At [practice name], we are inviting patients to read their notes on [patient portal name], our secure, confidential patient portal.
How does a patient get access to OpenNotes?
For a patient to view their notes, they first need to join [patient portal name], our secure and confidential website. Patients who are already registered in[patient portal name] don’t need to do anything. They will be able to log in and read notes for all visits or discussions that take place in ambulatory settings.
The notes will become available to patients on the portal only after the notes have been completed and signed.
What should I do if patients have general questions about OpenNotes such as where to find their notes, or why they’re not able to see notes?
The Patient FAQ is available on the [practice intranet name] and on [patient portal name]. The Patient FAQ may answer many of your patients’ questions. Patients may also contact the [patient portal name] team with specific questions at [contact email address].
General feedback from you, patients or clinicians may also be sent to: opennotes@yourdomainname.
What should I do if a patient asks to have his or her notes or medical record amended?
In the pilot study of OpenNotes, patients rarely requested a change in their record. When such requests were made, in several instances, the changes were felt on review to improve patient safety.\
Within [department/practice] there is a standard protocol for sending messages to clinicians (email, telephone messaging). Please check with your manager to ensure the process for communicating messages from patients regarding OpenNotes is known.
Changing a note occurs at the clinician’s discretion. He/she may do so by editing the record (such as a screening sheet or problem list) or by writing an addendum on the note.
If for any reason the patient is uncomfortable contacting the clinician, he or she may also contact the [Patient Relations Department] at [XXX-XXX-XXXX] or at [patientrelations@yourdomainname]. [Policy XXXX], called the Patient Request to Amend Protected Health Information, documents how a patient may formally request a change to the content of his or her records.
If patients request information on [patient portal name] and/or OpenNotes, what should I do?
You can direct them to important websites such as opennotes.org where they can learn more about OpenNotes. The patient FAQ may also be helpful. This information is available on [patient portal name] and available to you on [practice intranet name].You may also wish to direct patients with questions to [team member/OpenNotes champion name] at [contactemail address].
Contact Information
Patients may email the [patient portal name] team to ask questions: [contactemail address].
General questions or feedback from you or your clinicians may be sent to: opennotes@yourdomainname.
Example provided courtesy of OpenNotes and adapted for STEPS Forward™.
Source: AMA. Practice transformation series: OpenNotes. 2017.
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