On April 5th, 2021 Sunstone will join most other health care providers in providing access to the records generated following visits to our clinic. Open Notes is in compliance with the provision of the 21st Century CURES Act promoting consumer access to health information, transparency, and promote collaboration in care. We are looking at this Open Note transition as an opportunity to use the notes as a further tool of wellness, and to help our clients track their progress, participate in their care, and keep track of treatment goals. What follows is a FAQ developed from OpenNotes.org.

**What is an open note?**

After a visit or discussion with your clinician he or she writes a note that reflects the visit, summarizing the most important information. The note becomes a part of your medical record and may contain:
• a summary of what you told the clinician, also called a history;
• findings, such as your blood pressure, or current depression symptoms , labs or other results;
• your clinician's assessment or diagnosis of any medical conditions or symptoms, also called assessment or impressions;
• treatment plan developed with your clinician, and
• next steps: upcoming tests, follow up appointments, or referrals.

What is OpenNotes?

OpenNotes is not software or product, but rather a movement that urges doctors, nurses and other health care professionals to share the medical notes they write after an appointment or discussion with the patients they care for. Making notes open helps patients to read material that, through the federal Health Insurance Portability and Accountability Act (HIPAA), is already theirs to review and receive if they so desire. In 2010, 105 primary care doctors and 20,000 of their patients participated in a one-year study of OpenNotes. The patients were invited to read their visit notes online using a secure patient portal. At the end of the year, patients overwhelmingly supported the program and reported multiple health benefits. Doctors saw benefits for patients and little burden for themselves. And both patients and doctors wanted to continue to share notes. To read the study results, please go to www.annals.org/article.aspx?articleid=1363511.

What are the benefits of reading your notes?

Patients who read their notes report that they:

• have a better understanding of their health and medical conditions; • can better recall and follow their care plan;

• feel more in control of their health;

• take better care of themselves;

• do a better job taking their medications as prescribed.

• can identify inaccuracies in the record and play a role in the safety of care.

• feel comfortable sharing notes with care partners and others involved in their care.

• can communicate more clearly, helping to strengthen the partnership between themselves and their health care team. To learn more, visit opennotes.org

• Read your notes after a visit carefully to review what was discussed, including the care plan, medication instructions and recommendations for follow up appointments or referrals.

• Keep in mind that your provider uses the note to manage your care and to communicate with others involved in your care. It is not necessarily written in lay-person’s language. If you find the note difficult to understand because there are unfamiliar terms or abbreviations, this Medical Dictionary – Common Abbreviations may help. Medline Plus is a good resource to help you better understand your condition or medical terms.

• Review your note to make sure the information is accurate and up to date. Let Sunstone know about any changes that should be made to ensure the safety of your care.

• Read notes between visits to remind yourself of the treatment plan and to remember ongoing goals, resources, and referrals

• Use the note to make a “to do” list for yourself and take it to a visit with any clinician on your care team.

• You may decide to share your note with family, informal caregivers, or others who are involved in your health. Sharing is a great way to help manage care and to make sure your entire care team is on the same page.

• Before your next visit, read your note to remind yourself about your last conversation with your clinician and to prepare for the visit. Think about the things you’ve done since you last saw your doctor and the questions you’d like to ask.

• When you read the note it may trigger questions or remind you of additional information potentially important for your care. Try to take the appropriate action. Some issues can wait for a next visit; others are best addressed quickly.

What if I’m worried about what I might read or don’t want to read a particular note?

Note reading may not be right for everyone.

• For some patients just knowing that the notes are available if they ever want to read them or share them with a care partner is enough.

• It can be helpful to think of note reading like a medication, and talk with your clinician or care team about the benefits and side effects to determine if it’s right for you.

• If you’re nervous, it may be a good idea to start by reviewing a note with your clinician. Some of our clinicians are planning to start documenting the note during the visit with the client. Ask your clinician if this sounds interesting to you.

• You don’t need to read every note, but referring back to them, even occasionally, to remember what was discussed can help you feel more in control of your health care.

I can’t see any of my notes or a specific note I expected to see. Why?

Possible reasons include:

• You may need to locate the note within the electronic record.

• The note may have been written before OpenNotes started.

• The clinician may not yet be sharing notes.

• The note may not be ready. After the note is written and approved electronically, it will become available.

• Your clinician may have chosen not to share this particular note. We encourage you to talk with the clinician to make sure you understand the reason for not making a particular note available. If you have questions, feel free to ask.

What should I do if I think I may have found an error in my note?

If it’s a serious issue, like a potential mistake that could affect your care immediately, contact the office clinician who wrote the note and tell them about your concern. For other inaccuracies, be sure to write down the correction and bring it to your team’s attention so your records can be updated. Use your best judgment about small mistakes, such as spelling or grammar. Clinicians often dictate their notes and rely on others to type them. If these less immediate issues feel important, bring them up at your next visit.

**How do open notes affect confidentiality and privacy?ow do open notes affect confidentiality and privacy?**

It’s important for you to know that open notes do not change the confidential relationship you have with your health care team. Only you and the care team directly involved in your care can access your note. What does change is your ability to share. With OpenNotes, it’s easier to share your medical information with a care partner, family member, or others, but only if you choose. You are in full control of who has access to your note, which means you are in full control of your privacy.
To help ensure your privacy, please remember to:
• keep your login name and password private; and
• wherever you look at your account, always exit by selecting “sign out” when you are done.

How can I send general suggestions or thoughts about OpenNotes? Who should I contact?

If you have a specific comment about your own notes, please contact your clinicians. For general suggestions or thoughts about OpenNotes, please e-mail myopennotes@bidmc.harvard.edu

We appreciate you! Thank you for choosing us to be on your team: we look forward to improving your healthcare experience together.

Coming Soon....Open Notes!