ResourceOpen notes help make care safer for patients.
Open notes are an important tool for improving patient safety. Patients are often overwhelmed at increasingly time-compressed healthcare visits. A lack of adherence to next steps such as tests or referrals can have serious consequences for safety, diagnostic delay, and quality of care.
Macda Gerard, MD
An estimated 40-80% of information from medical encounters is forgotten or misremembered by patients.
In one study with over 10,000 participants:
Approximately 75% of surveyed patients and parents of pediatric patients reported that reading notes helps them understand the reason for tests and referrals.
About 50% reported that reading notes helps them complete tests and referrals.
In a study of over 12,000 primary care tests and referrals, reading notes was associated with significantly higher odds of timely completion of tests and referrals.
“It doesn’t make me lose confidence in [clinicians] and, in fact, I think I respect them more for admitting that there was a mistake and apologizing for it rather than sort of brushing it under the table.”
—Eileen Hughes, patient advocate
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Open notes can improve note accuracy and help identify mistakes. Clinicians review thousands of notes, but patients review only their own. Patients know themselves best. Reviewing their own notes helps them and their care partners to be partners with clinicians in safer care. Open notes can empower patients as safety partners and increase transparency and inclusivity. Patients reading their notes can identify inaccuracies, prevent missed follow-up care, and better complete tests and referrals. As demonstrated in studies addressing open disclosure of medical errors, open and honest communication may help decrease litigation. Open notes may also build trust, an important factor in minimizing, and at times preventing, conflict.
U.S. experience with doctors and patients sharing clinical notes BMJ (2015)
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 Quality & Safety (2017)
7% of patients reported contacting their clinician’s office about something they read in their notes.
29% of those patients did so because of a perceived error in the record, suggesting an opportunity to improve safety.
85% of those who reported an error were satisfied with how their clinician handled the issue.
No clinicians reported ordering additional tests or referrals as a result of open notes.
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Yes. When patients do not or can not take their medications as prescribed, they are likely to have poorer health outcomes. Our research suggests that reading notes can help patients understand and take their medications as prescribed. Notes can also help patients to feel more engaged in their care, and more engaged patients are more likely to have good outcomes.
Patients managing medications and reading their visit notes: A survey of OpenNotes participants Ann Intern Med (2019)
2/3 of surveyed patients reported that notes help them understand the reasons a medication was prescribed and make them feel more in control of their medications.
14% reported that reading the notes makes them more likely to take their medications as prescribed. In addition, reading notes can improve quality of care by fostering stronger relationships between patients and their healthcare providers and shared decision-making.
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Patients who read notes can identify clinically relevant documentation errors and contribute to diagnostic accuracy. Electronic Health Records (EHR) can have unrecognized documentation errors that are then propagated from one visit to another. While clinicians oversee the care of hundreds, sometimes a thousand patients or more, patients and care partners only look at their own open notes, and they are “experts” at their own medical history. This can allow them to catch and report documentation errors before they potentially lead to serious consequences.
21% of 30,000 surveyed patients reported at least one mistake in their notes.
Among those patients, 42% said the mistake they found was somewhat or very serious.
26% of doctors in another survey reported that they anticipate non-trivial errors in notes.
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Health systems need to develop ways for patients and care partners to report errors so that the right information gets to the right person at the right time. Researchers are working on innovative ways to team up with patients and families to ensure safe care. This is especially important for diagnostic safety in ambulatory (out-patient) care, because patients and families have unique information that is important for making a correct and accurate diagnosis that healthcare providers may not know.
For example, patients/families are the first to know about changes in symptoms, and they are often the only ones who know about events that occur outside the healthcare center or between visits; such as tests at other centers or major life events. They are the only “connecting thread” between different visits and are therefore in a unique position to notice important safety-related issues that providers may not observe – so called “blindspots.”
Looking for a way to help patients/families bring their unique insights back to clinicians and the medical record, researchers co-developed with patients a tool called “OurDX.” Before upcoming visits, patients received an invitation to report their visit priorities, recent medical history, and potential concerns. The tool helped to align patient and clinician agendas, obtain accurate histories in patients’ own words, and identify potential blindspots, so that they could be addressed in real time. Practical tools to help patients and families engage in the diagnostic process is critical to improving diagnostic safety.
Partnering with patients and families living with chronic conditions to coproduce diagnostic safety through OurDX: A previsit online engagement tool J Am Med Inform Assoc (2023)
Patient and family contributions to improve the diagnostic process through the OurDX electronic health record tool: A mixed method analysis BMJ Qual Saf (2023)
Researchers developed and studied a reporting tool that patients could fill out after reading a note. Of the submitted reports:
21% identified a possible documentation error.
2/3 of these reports identified an actual or possible safety concern, and the majority led to a change in the medical record or to patient care.
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Studies have shown that patients in marginalized populations may particularly benefit from open notes for understanding their health and engaging in their care. Patients who have traditionally been marginalized by society—including less formally educated, non-English speakers, people of color, and others—may be at risk of healthcare disparities and also face several barriers to understanding, remembering, and completing next steps in ambulatory care. In a large study at 3 sites, marginalized patient populations reported benefits from note-reading that were as substantial as, or more substantial than, those of their counterparts. Patients with lower levels of formal education as well as Black, Asian, and Hispanic or Latino patients were more likely than their counterparts to report notes as extremely important for remembering their care plan, feeling informed, and making decisions about their care. When using the OurDX tool, patients self-identifying as Black or Multiple races were more likely to report a diagnostic breakdown in their notes. Patients who preferred a language other than English were five times as likely as English-preferring patients to report they did not feel heard in the diagnostic process. Identifying these concerns at the point of care can help raise clinician awareness about diagnostic processes at risk, and motivate responses to prevent further delays, problems, or downstream harm.
Partnering with patients and families to improve diagnostic safety through the OurDX Appl Clin Inform (2023)
The importance of visit notes on patient portals for engaging less educated and nonwhite patients: Survey study J Med Internet Res (2018)
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Open notes offer a tangible way to teach medical students and residents in GME training programs about patient engagement and its relationship to patient safety. In particular, open notes may serve as a powerful educational tool for medical students and resident physicians to receive feedback on accuracy and communication with patients. In one study, a majority of surveyed residents indicated that patient feedback on their notes could improve communication with patients. As patients can identify and report documentation errors, open notes may also be used to teach resident physicians how to communicate effectively with patients about perceived errors.
Before sharing notes, residents and their clinic preceptors had mixed views about open notes; while they anticipated patient benefits, they worried about effects on workflow
The majority of residents anticipated that open notes could improve patient engagement and patient safety
Residents believed that patients should report errors in their notes
Open notes offered a tangible way to teach patient engagement in GME programs
Educational efforts could be linked directly to safety curricula
Residents were interested in learning how to write notes that patients read
Residents reported that feedback from patients on their notes could help them improve communication
Open notes may be used in the future as a way to provide learners feedback on communication during the visit and on their visit notes
Patients could identify copy/paste behaviors
Students learned lessons powerfully when provided by patient feedback
OpenNotes in teaching clinics: A multi-site survey of residents to identify anticipated attitudes and guidance for programs J Grad Med Educ (2018)
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Research shows that greater healthcare transparency can significantly improve trust and strengthen the patient-doctor relationship. Care plan adherence and follow-up, speaking up about safety concerns, and participating fully in shared decision-making—key behaviors for strong patient-clinician partnerships—are influenced by patient perceptions of trust, teamwork, and activation in healthcare. Such relational attributes are central to patient partnership in safety and can be strengthened by the transparency offered with open notes. Transparency and trust go hand-in-hand. Even the invitation to read clinicians’ notes alone, regardless of whether patients read notes or not, may strengthen the patient-clinician relationship.
Sharing notes can strengthen or strain trust in the provider. For patients who already had negative perceptions of the doctor, faulty or judgmental notes could further cast negative feelings about the provider. However, despite clinicians’ concerns about errors and offending language, open notes overall more often helped to strengthen this partnership. In fact, 97% of surveyed patients, families, and care partners report the same or greater trust, teamwork, and alignment of goals with providers after reading at least one note. Patients who were older, male, non-white, had fair/poor health, or had less formal education were more likely to report feeling better about their doctor after reading their notes. Patients who read more notes indicated improved shared-decision making with their clinicians.
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 (2017)
Tackling ambulatory safety risks through patient engagement: What 10,000 patients and families say about safety-related knowledge, behaviors, and attitudes after reading visit notes J Patient Saf (2021)