Patients Can Now Obtain Access to Physician Clinical Notes

Under state and federal laws, patients have the legal right to obtain access to and copies of their medical records. Trying to understand all of the medical jargon and technical terms can be daunting. New federal rules will now allow access to a physician's clinical notes in addition to the medical record. The goal is that these notes may provide patients a clearer understanding regarding their medical condition, diagnosis, treatment plan and medications which may not be as apparent in the medical record. Some physicians and others have raised a concern, however, that such access may result in less transparency to the patient. Objective assessments but unstated comments or suspicions about the patient's condition, habits, drug dependency or mental health might not be included although possibly relevant for future treatment. Moreover, in the event of any subsequent litigation due to a patient injury, these clinical notes will be discoverable along with the medical records.