Why Patients Need Access to Their Digital Medical Records

The provision of high-quality healthcare and the facilitation of communication between various healthcare specialists depend on accurate medical record keeping. Outsourcing medical transcription is a realistic way to assure effective medical record management in the era of widely used electronic health records (EHRs).

Working with a seasoned medical transcription business may assure accurate documentation of the patient's medical history, alleviating the burden of paperwork on nurses and doctors, increasing the productivity of their workflow, and enabling them to spend more time with patients.

Personal health records (PHRs) are increasingly being used as mobile device usage grows and patient technical proficiency rises. EHR systems and PHRs are connected. Patients will have unrestricted access to all of their electronic medical record chart notes as of April 2021 under a provision of the 21st Century Cures Act.

The following components of the electronic medical record are accessible to patients:

•    history and physicals
•    imaging narratives
•    lab reports
•    consultations
•    progress notes
•    discharge summaries
•    pathology reports
•    procedure notes

Why Is It Vital That Doctors Share Patients' Digital Notes With Them?

Open notes are strongly supported by the American Medical Association (AMA). Shared visit notes, also known as open notes, have been shown in studies to increase care transparency and to potentially improve patient-provider trust and treatment adherence.

Patients view note reading as being extremely important for managing their health, and they frequently share their notes with others, according to the results of the first comprehensive study of patient experiences with a wide range of doctors, nurses, and other clinicians working in practises that shared notes.

1. Improves patient comprehension of their health information by assisting them in better understanding their doctor's advice, which will enable them to take the necessary steps for their health or make the right decisions regarding their health.
   For instance, a well-formatted radiological report with structured data and clear content display, including patient summaries and infographics, can significantly increase patient comprehension and inclusion. 

2. Patients are reminded of what was mentioned during the visit: Regardless of their level of education, patients only recall around 49% of the decisions and suggestions made during meetings with their doctors, and about 15% of the information was  remembered incorrectly or not at all.
   Study shows that the more anxious patients are during that visit, the less they can recall. However, another 36% of it was remembered with the use of prompts. Therefore, seeing medical notes can aid patients in remembering and better understanding what was said during the visit.

3. Sharing notes with patients can assist them in appropriately adhering to their medication regimens, which improves treatment adherence. Patients are more likely to take medication as directed when they read their notes and get the rationale behind a prescription.
   It might also stop issues like forgetting to complete or refill a prescription, taking the incorrect dosage or timing of a medication, and failing to recognise the consequences of inappropriate dosing, side effects, or drug interactions.

4. Encourages shared decision-making: Giving patients access to their medical records enhances communication and encourages shared decision-making in addition to boosting treatment adherence. Patients can gain a better understanding of the doctors' reasoning, the advantages and disadvantages of various treatments, and the viability of medical options by reviewing their medical records. Patients will feel more confident in their ability to manage their health as a result.

5. Informs patient's caregiver: Giving family members and caregivers access to notes will enable them to work more effectively with doctors and nurses to deliver better care. In order for caregivers to provide clinicians with insights about the patient's symptoms or behaviours, needs, and preferences—all of which are critical for providing effective support—they would require access to information regarding the patient's diagnoses, test results, and prognosis.

6. Improves safety and aids in the detection of errors: Patients who read their notes may find errors that are clinically significant. The most frequent errors seen in diagnoses, medical histories, prescriptions, physical exams, test results, notes on the wrong patient, and sidedness were among the most serious problems that patients identified. When patients disclose these errors, record accuracy and patient involvement in safety can both increase.

7. Increases trust: Even if patients don't read their notes, just being aware that the note is available increases their trust in their healthcare provider and the facility where they're receiving treatment. This is particularly crucial during a public health emergency like the COVID-19 epidemic when public confidence in doctors and medical research has declined.

Clinicians should focus on the accuracy and timeliness of the information because open notes are legally required. Services for medical transcribing may be crucial in this situation. Reports must also be jargon-free and patient-friendly in order to encourage patients to use the medical information in their records.

For instance, the current push to provide interactive, patient-centered radiology reports offers a singular opportunity for radiologists to directly understand patients' requirements and for patients to successfully express their medical information. Medical practitioners can get assistance from medical transcription services as they work to give patients and refer doctors high-quality medical reports.