If you use a patient portal or smartphone app to access your familys health care information, you may have noticed some recent changes. Notes from the health care provider are now available. This change is due to a national law called the 21st Century Cures Act.
What Is the 21st Century Cures Act?
Part of the 21st Century Cures Act law aims to improve patient access to personal medical information. All health systems must release certain types of health information to the patient portal as soon as it is available. This began with test results and now includes clinical notes.
One goal of the Cures Act is to make it easier for people to see their medical information. This can help parents feel more informed and empowered about their childs medical care. You could ask for your childs medical records in the past, but now youll see much of this information more quickly because its added to the portal promptly.
What Might Be in Clinical Notes?
Looking at clinical notes is new for many parents. Clinical notes will vary depending on the provider, the type of visit and where your child receives medical care.
Clinical notes may include:
- Chief complaint (CC): The reason your child saw the doctor that day.
- History of present illness (HPI): A record of your childs symptoms and when they started.
- Vital signs (VS): Any measurements taken during the visit, including your childs weight and height, blood pressure, and heart rate, to name a few.
- Review of systems (ROS): A series of questions the doctor may ask you (or your child if theyre old enough to respond) to find out what symptoms your child has. This could include how your child is breathing, if they have a fever, feel tired, or have a rash, to name a few.
- Physical examination: Your providers description of what they noticed when checking your child, including how the heart and lungs sounded, how the skin looked, if a body area is tender or swollen, etc.
- Results: Notes from the doctor about lab results or imaging scans, such as X-rays. The actual test results might be kept in a different place in the portal, but the provider may reference them or interpret them in the note.
- Assessment or impressions: What the doctor finds to be the cause of your childs symptoms (the diagnosis).
- Plan: The doctors treatment recommendations.
- Orders: Information about prescriptions, procedures, tests, referrals to specialists, and follow-up care.
Why Are Clinical Notes Important?
Doctors have always kept notes about each patients medical visit. The notes are a record of why the doctor made the diagnosis and recommended the treatments. It captures what conditions the doctor considered and ruled out.
When your child needs to see a different provider, the information gives them a place to start, which can help avoid unnecessary tests and questions. And if you go back to see the original provider, the notes are a good reminder of what happened last time.
What if I Don’t Understand the Notes or See Something Surprising?
Clinical notes are intended for health care professionals, so you might not understand some of the abbreviations or terms. You can call the providers office with questions or check this list of common medical abbreviations.
You could read something in the notes that is news to you. Some information will be your doctor describing their decision-making process for your childs care. Remember, doctors must consider all possible causes of symptoms. Some notes might refer to all the conditions they considered before coming to a diagnosis, even if it was unlikely that your child had that problem. They will document why and how they came to the conclusions they did.
For some, reading all the things their doctor thought about may be reassuring. But for others it can feel like too much information. Deciding to read the notes is a personal decision. Just because they are readily available doesnt mean you have to read them. Sometimes just knowing they are there if you need them is enough.
Also, you may read something that you remember differently about the visit. If so, contact your doctors office. You might have misunderstood something, or the office may need to make a correction.
How Can I Use Clinical Notes to Help My Child?
Reviewing the doctors notes after a visit can help you better understand your childs diagnosis and treatment plan. Often, theres a lot to take in and remember at a doctors visit. Its even harder if youre distracted by a sick child. Reviewing the notes can be a good reminder of what happened during a visit.
The clinical notes can help you understand:
- The types of follow-up tests or appointments your child needs
- The reasons for, dosages, and possible side effects of medicines.
- Changes in your childs symptoms or behaviors that you should watch for.
- When to contact the doctor about changes to your childs condition.
- What to do if your childs condition doesnt improve or gets worse.
- ^ 21st Century Cures Act (www.healthit.gov)
- ^ list of common medical abbreviations (medlineplus.gov)