The CURES Act will take effect on April 5, 2021. This will allow patients to access their health information and share it with third-party apps. Importantly, it will also allow access to physicians’ notes.
We are aware that some hospitals have not been as active in educating and training on this required release of records to patients. Once signed, your notes or H&P will be immediately available to patients to see and read. We offer the following suggestions to consider as you address these new changes:
- Minimize use of abbreviations:
- Avoid medical jargon that may not be understood by the patient
- Discuss the content with the patient before you write it
- Write as you speak with the patient in your office or on the phone
- Write as if you are still speaking with the patient and explaining something
- Consider your notes to be reaffirming and educational
- Enlarge the font size when you want to emphasize something such as reminders:
- If documentation could cause harm to the patient, discuss a plan with the patient and consider blocking the note from the patient portal. The patient can always submit a written request for the records at a later date.
- Use supportive and less judgmental language:
Additionally, patients will have access to all laboratory reports and may see them before the provider does. This will include HLA typing, cancer screening, and any lab results that may be listed as abnormal. It will be important to prepare patients for what they may see in labs and document this discussion in your notes.
Providers may wish to consider blocking:
- HLA or any genetic testing
- Transplant selection consults
- Independent Living Donor Advocate
- Social workers
- Psychiatry/psychology.
References
1.Rodriguez JA, Clark CR, Bates DW. Digital Health Equity as a Necessity in the 21st Century Cures Act Era. JAMA. 2020 Jun 16;323(23):2381-2382. doi: 10.1001/jama.2020.7858. PMID: 32463421.
2. Klein JW et al. Your Patient is Now Reading You Note: Opportunities, Problems and Prospects. The American journal of Medicine 2016; 29(10) 1018-1020. http://dx.doi.org/10.1016/j.amjmed.2016.05.015
3. Federal Rules Mandating Open Notes. https://www.opennotes.org/onc-federal-rule/ Accessed March 3, 2020
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