Open notes mandate in the US

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Nikki J

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PALS
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I think many places are doing this already. the Mass General system does. most medical tests and visit notes should be viewable online by you as soon as they are done. if you are not already signed up with your patient portal please consider doing this. It starts 11/2/20

 
I see this Nikki's Thread didn't get much attention.

My opinion... I encourage readers to read Nikki's attachment.
Again, my opinion... it's good thing.

Maybe when some of these "Could this be ALS'ers" post about
getting their medical records they could be referred to this.

Thank you Nikki for being on top of things like this and
and so many things you keep us abreast of.

Am I drumming :) to the wrong beat here?
 
Thank AL I was considering a sticky in CiHALS No excuse anymore for U s people not to have their emgs and results of exams

i think knowledge is power as they say but I can also understand PALS not wanting to read everything their doctors write
 
Nikki, as you wrote....

"... but I can also understand PALS not wanting to read everything
their doctors write."

True.

Maybe you can correct me on this... I red it line for line and from
previous experience looking in between the lines.

Possibly, you (anybody) will also have access to the doctors
observational notes of the patient during the visit. Something
outside of typical written medical record statements.

As I've written before, a good Neurologist watches the patient
from when he walks into the room or until the patient or him/she
leaves the room. Like how the patient gets out of the chair, taking
their shoes off and on, crossing their legs if they do while sitting,
getting up on the table and more. Their little secret
notes of observations. A good ALS specialists Neurologist.
Will this be available?

My opinion, if I'm right, this would help a patient decide if they may
want to consider another Neurologist or address him/her about it.
 
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My neurologist does not write/type in front of me. Ever. She looks at me and talks to me. I am lucky.

it is illegal to have notes on a patient separate from the medical record that are retained. quick reference scribbles if needed to write a note should be shredded immediately after writing the real note. Every clinician has their own style and observations of gait, posture ,how you tie your shoe are perfectly valid to include
 
Ok, that's hard for me to take in that a Neurologist doesn't have
observational notes of a patient during an office visit separate
from the written report. Not noted during the visit but after or
before he/she sees the next patient and his/her notes for the
next. Memory from last your last visit and all the patients
in between?

Whatever. Thanks.

PS. I remember way back when my Neurologist, who was one
of the best, after physical tests he did make notes in his folder.

Are we talking different situations here?

I'm in the same situation now too... we just talk.
Whatever... :)
 
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Can they write after the visit in your chart? of course. But it has to be in the chart. Further with electronic records you electronically sign when you are done and it is locked. Alterations later will show date time and who did it. The practice group usually gives a deadline for locking and submitting
 
Ok, I write this in jest.... :)

Fess up.... are you really a Neurologist or lawyer incognito? :)
 
I say this sincerely, we all need to be grateful that your ALS has not
affected your cognitive sharpness, mental depth, reading comprehension
and you being spared of any FTD issues.

You bring good info to the Forum from your dedication to this.

I hope our exchange has members reading.
 
Thank you Al. I do worry about cognition especially because I am c9. I appreciate the kind words.

it no doubt is stating the obvious but the records will be available when the note has been finished and submitted, the mri read by the radiologist, etc. how quickly that happens depends on what it is and how the responsible party is doing at that particular time. A neuro might complete their note immediately ( unlikely) at lunchtime, that night or maybe the weekend. the law just says when it is available in the system you can see it. Which often means before your doctor for blood tests, xrays etc. unless it seems really catastrophic ( in which case the lab or radiologist probably notified your doctor) be patient and remember they could be with another patient or otherwise occupied.
 
that was in response to clearwater's post, btw. :)
 
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