Since 07/01/2021, patients and clients were given online access to the health care notes that doctors or medical providers wrote after the appointment. We call this OpenNotes. You will be invited to read your notes on SMHW MyHealthRecord portal – your secure, confidential patient website. Please read the brief introduction to OpenNotes below, and see our patient FAQ handout for more information.
What’s in the notes?
Each time you have an appointment or discussion with your clinician they describe what happened in a note. Notes often start by listing the symptoms or questions you have. Some also list the medications you take or medications prescribed during a visit, findings of your physical exam (such as blood pressure or how your lungs sound), lab tests ordered, and the overall plan for taking care of you. Notes become a part of your medical record.
Why are we sharing notes with you?
We know from research that patients both like and use OpenNotes. They report that reading their notes is a way to better understand and feel more in control of their health care.
When will you see a note and how will it work?
Starting 07/01/2021, if you choose to see your notes, go to your MyHealthRecord portal, and select the “Personal Medical Records” button on the left side of the screen. Available notes will be listed on the left side of the screen under “Personal Medical Records”. A note will typically be posted within 1 week of the date of the encounter. Notes pertaining to visits before 07/01/2021 will not be displayed. If you would like to review notes prior to 07/01/2021, you must submit a medical release of information form.
How do we know the notes are private and confidential?
OpenNotes will not change the confidential nature of the notes your clinicians write. Only you and the clinicians involved in your care have access to these notes. If you share access to your account with your family or other caregivers, they will also be able to read these notes. We advise against sharing your password information and allowing access to your myhealthrecord portal. Here are steps you can take to help keep your information secure:
- Remember to keep your SMHW Portal login name and password private. Reset your password to a new password if you have shared it with others and do not want your records viewable to anyone other than yourself. You can reset your password at https://password.ucsf.edu/ Be aware that your password change will reset the password on all of your UC system accounts.
- Wherever you look at your account, always exit the SMHW portal by selecting “Log out” when you are finished and close the browser window. (Click the dropdown arrow on the upper right corner of the screen, next to your name).
What if you do not want to see your notes online?
Open Notes are required for all UC SMHW to comply with the congressionally approved 21st Century Cures Act Mandate. The only way to opt out of open notes entirely is to decline access to your student myhealthrecord portal. This is not recommended; the myhealthrecord portal facilitates access to your entire health record at SMHW. Importantly, one option you do have, if you don’t wish to see your notes, is to simply not access them in this manner. Should you need your health records for some reason, it is still entirely possible to get them by submitting a medical record release request on the myhealthrecord portal for a copy. If you have any questions about Open Notes, please contact your provider to discuss further.
This document is a modification of a resource provided courtesy of OpenNotes and adapted for STEPS Forward™.
Source: AMA. Practice transformation series: OpenNotes. 2017.