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The Open Notes Revolution

Dec. 3, 2017


Do you want to know what your doctor wrote about you during your consultation? Well, since August Medplus patients can. Medplus is one of the trail blazing practices in New Zealand who have decided that sharing the medical records with patients aids understanding and is an enabler of better healthcare.

If you have seen a GP since 1st August 2017 you will be able to access your doctor's notes on the Health 365 patient portal. Even though we have not yet publicised this, we have seen that notes section of the portal is getting a huge number of hits on line, and hope that this new development is one you will find useful and interesting.

You will be able to see your full consultation notes from the day after your consult, but possibly earlier. Theoretically our 15-minute consultation times are supposed to comprise 10 minutes of face to face time and 5 minutes of note keeping for the GP. However, as many of you will appreciate, the consultation is often extended beyond the allotted time. This means that some of our GPs actually only record the brief details during the consult and end up writing up the more comprehensive notes in their evenings. Please account for this if you log on immediately after your consultation, we may not have finished.

The medical record inevitably uses medical terminology, however much of it will be comprehensible. The notes are formatted in a standardised medical way, starting with your presenting complaint (for example, "headache"). Next is the history, detailing the problem, its duration and relevant facts. Our opinion of what is relevant may seem irrelevant to you, for example, if you are coming in with fatigue we are likely to be documenting findings related to your mood, even if they are negative findings. Some doctors write out their notes in sentences and paragraphs, others use bullet points, we all have our own style. The history is followed by the examination – and this is the part that will probably contain the most jargon and standard medical abbreviations. Then there is the diagnosis, recorded in impression. There is also a list of actions, which may include prescriptions or tests and possibly a plan.

Doctors around the world are generally very nervous about opening the notes, but patients really find it useful. We have reassured our team that the international experience is that patients are really not concerned about spelling errors, typos and grammar, and are very forgiving of these issues. We would be very grateful if you could be understanding too!

You will unfortunately not be able to see notes prior to 1st August 2017, but will now be able to read hospital letters. Please note, many hospital doctors will not realise that their letters are now visible. We try very hard to ensure we do not end up breaking bad news via the portal, but that is one of the risks we are aware of.

We also want you to be aware that your privacy and the security of your medical record very much depends on you taking the utmost of care with your portal password. Please treat it like a bank pin and do not disclose it to anyone, do not write it down and do not use a password that you use for other websites.

If you have not done so already please do log onto the portal and have a look around your medical record. What you can access is evolving, and we hope it will not be long before you can add to your record yourself.

Of course, please let us know if there is any erroneous information in your record. We can never go back and change what has been written, but we can add an addendum.

Very occasionally we may withhold access to medical records if we feel this will not be in a patient's best interests. This is entirely at the discretion of the medical team.

Many of our patients have commented on how useful access is to their record, particularly if they are needing urgent healthcare away from home. Remember, you now can use your smart phone, device or computer to access your records from wherever you are in the world.

For more information about how open notes can benefit you visit this North American website:

www.opennotes.org