FAQs for Patients
I already get a visit summary after my visits. What is the difference between a note and a visit summary?
A note contains a detailed account of your visit, including the history, exam, relevant lab or study findings, and the clinician’s assessment and plan of care.
A visit summary gives you a more limited snapshot of your visit including the “vital signs” recorded at the visit, a list of your medications and a summary of follow up visits that are already scheduled. The visit summary sometimes also includes specific instructions your doctor provides for you.
Together the visit summary and your note provide a far more complete picture of your visit.
What if I have questions about information in the note?
A wealth of resources available online can help you better understand your medical condition or medical terms written in the note. If you have an unanswered question, you can perform a quick online search, jot down the question to discuss with your doctor at the next visit, or contact your health care provider’s office. You may want to ask your provider about good websites or online resources to turn to with questions about your particular condition.
Keep in mind that the visit note is part of your medical record, which is used by many doctors and other clinicians to take care of you. The visit note is not necessarily written in lay person’s language since it is a document that is used professionally within the health care system. Some of the language may be difficult to understand—it may include abbreviations or terms your care team uses to communicate with each other efficiently so that members of your care team are kept updated about your health or medical conditions.
Can I share my note?
Any interaction between you and your provider is confidential. But with OpenNotes it is your decision whether or not to keep it private- whether to share your note with anyone. Indeed, you may find it extremely helpful to share your notes with family members, friends, or caregivers who assist in your health care.
How long does it take for a note to be available?
After the health care provider writes and approves the note, the note will be available for you to review. This may take a few days or a week, especially if the clinician is very busy and may not be able to write or review the note immediately after your visit.