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Open Notes and Immediate Access to Test Results
Along with test results, UC Davis Health is pleased to share online access to most of the notes our health care team writes about a patient’s visit or hospital stay. This is related to the national movement toward “Open Notes.” You are invited to read your notes on MyUCDavisHealth – your secure, confidential patient health record portal.
What’s in your notes?
Each time you have a visit to a clinic or hospital, your physician, nurse, therapist, and other care team providers describe what happened in a note. These documents serve many purposes. Mainly, they are for communications between members of your care team. But they also support quality improvement, billing, and legal requirements.
Clinical notes include medical terminology and abbreviations written in a standard format. The Resource button on MyUCDavisHealth offers multiple information sources including Healthwise, Medline Plus and additional health education resources to clarify information in the notes. A typical note contains four sections:
- Subjective – Patients and other sources provide the subjective information. This includes the reason for the visit, current symptoms, and may include other details, such as past medical information or medications. Think of this as the ‘story’ of the reason for your hospital or clinic visit.
- Objective – Vital signs, physical exam, and test results are included in the Objective section. This is what the team learned by examining you and doing tests.
- Assessment – The clinician describes their diagnosis, or potential diagnoses, based on the subjective and objective information from the visit. It may include a differential diagnosis, which is a discussion of possible diagnoses considered, including some discarded diagnoses, based on the information from the visit.
- Plan – Finally, the plan is about next steps; what the care team recommends or is going to do as a result of the visit and evaluation. The plan may include behavioral or lifestyle changes, further testing, prescription or over-the-counter medications, referrals, procedures, as well as follow-up appointment needs.
Some notes must include additional information due to various regulatory requirements. Physicians and care providers will discuss your condition and treatments during your visit, provide an After-Visit Summary (AVS) to summarize that visit, and now you will be able to view the visit notes in your patient health record portal following the visit.
Providers’ notes have always enabled the efficient transfer of information and details about a patient between care team members. Now, patients and their authorized caregivers can easily access that information too.
Why are you sharing notes with patients?
We know from research that patients both like and use Open Notes. They report that reading their notes is a way to better understand and feel more in control of their health care. If you share access to your MyUCDavisHealth account with your family or other caregivers, they will also be able to read these notes, which can help them understand how to better help you.
When will I see a note and how will it work?
For outpatient visits, you will receive a MyUCDavisHealth alert when a new After-Visit Summary is available for you to read, often on the day of the visit. For hospital stays, notes will appear after they are signed. There are times when they need to be signed by both the note author and a senior physician.
To see your notes, you will select the “Visits” tab on the top of the screen, then select the “Appointments and Visits” button, and finally select “View Notes.”
Can I see test results?
It’s important to keep in mind that you will often have access to your test results before your own provider sees them or has a chance to contact you to explain the information. That means results could show something surprising, upsetting, or not be easily understandable without some explanation. We recommend patience and perhaps not looking at new test results if you would rather not get such news until your provider has an opportunity to explain what it means.
How do I sign up for MyUCDavisHealth if I don’t already have an account?
Go to health.ucdavis.edu/login/ and click “Create an Account.”
How do I know the notes are private and confidential?
Open Notes will not change the confidential nature of the notes your clinicians write.
Here are steps you can take to help keep your information secure:
- Remember to keep your MyUCDavisHealth login name and password private.
- Wherever you look at your account, always exit MyUCDavisHealth by selecting “Log out” when you are finished. Don’t forget to close the browser window, too.
Other Frequently Asked Questions
Every health care provider writes a note summarizing the most important information discussed with a patient after a clinical visit. Information and details about symptoms, an examination, test results, a diagnosis, a treatment plan and next steps are all part of a provider’s notes. As a UC Davis Health patient, you have access to this information.
Patients have long had the right to request their clinician’s notes and test results. What’s changed in recent months is that your provider’s clinical notes and results are now almost immediately available via MyUCDavisHealth. This is what’s known as “Open Notes.” It was developed as part of federal law called the 21st Century CURES Act, which requires all health care providers to practice Open Notes.
If you do not want any specific notes or results to be available through the MyUCDavisHealth portal, just ask your care team not to release them. You have the right to keep them hidden from others who have access to your account, or not see them if you don’t want to.
Research has shown that patients benefit from and enjoy having access to their provider’s notes. There’s even a non-profit organization dedicated to enhancing the Open Notes movement for the benefit of patients and health care providers alike.
Notes are typically available via MyUCDavisHealth once they are signed off by your health care provider or the appropriate UC Davis Health personnel.
Yes, most will be available to you as soon as the test report is completed. It’s important to keep in mind that you will often have access to your test results before your own provider sees them or has a chance to contact you to explain the information. That means results could show something surprising, upsetting, or not be easily understandable without some explanation. We recommend patience and perhaps delaying looking at new test results if you would rather not get such news until your provider has an opportunity to explain what it means.
The website medlineplus.gov is a great place to identify common medical terms, abbreviations and acronyms. In addition, during an appointment, ask your care team member to help when you don’t understand something in your notes.
You should see almost all notes and results from the UC Davis Health teams who provided direct care to you. However, some test results such as HIV, hepatitis antigens, pathology results, and abuse of drug results are considered sensitive information here in California. Those results are not shared immediately and will typically be withheld until a UC Davis Health provider has been able to provide and explain the results to the patient. Also, if the note is made as part of a research study you have agreed to participate in, that note may not be immediately available.
Older clinical notes from UC Davis Health providers, prior to November 2020, are also not immediately available online through MyUCDavisHealth. Older notes are available, as they have been for years, through the traditional Health Information Management (HIM) request process.
Open Notes do not change privacy and confidentiality in any way. Our health care teams – and every UC Davis Health employee – rigorously maintains all the patient privacy guidelines and protocols that have always been in place. Only you (or those to whom you have granted proxy access) and your care team can see or access your notes through your MyUCDavisHealth patient portal.
However, this expanded access for patients means it is easier to share your medical information with a family member, or care partner, or anyone else you choose. Please remember to:
- Always keep your MyUCDavisHealth login ID and password private.
- Wherever you access your account, make sure your also properly exit your account when finished. Don’t forget to always log out when done.
When your child is 0 - 11 years old, Open Notes enables you to make the choice about sharing medical information with others involved in your child’s care. It’s a good way to keep caregivers and specialists up to date on treatments and progress, especially when a young patient is seeing multiple specialists.
On the other hand, parents of minors between 12 - 17 can have limited access to their child’s medical information with a signed authorization from the minor.
Of course, as with every patient, protecting the privacy of your child’s health information is a top priority for UC Davis Health and its care team members. So, just as you do with your own account, remember to keep your login information and password private. Whenever you visit your child’s health record online, remember to sign out, too.
If you think there is an inaccuracy or error in your clinical note, please contact Health Information Management (HIM). We have a standard process for correcting or adding to a patient’s medical records in line with federal and state regulations.
The best way to understand your notes and be certain everything is correct is to ask your care team about them at your next visit. If you have questions about a clinical note after the note is posted, send your question to the clinician’s office via MyUCDavisHealth. Better yet, write your question down and discuss with your provider at your next appointment.
The OpenNotes organization also provides helpful information about how to make the best use of your notes.
It is part of long-range plans, but not currently available.
Learn More About Open Notes
Visit the OpenNotes websiteHelp and Support
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