What is a Visit Note?
When you see doctors or other clinicians for an appointment, you may notice them recording notes by hand or on a computer during the visit. These visit notes, which summarize what was discussed between the clinician and patient and what the clinician found or measured during the appointment, become a part of your medical record.
In this digital age, patients have access to ever-increasing amounts of health information, such as their laboratory results, medication lists and other parts of their medical record. Notes are the thread that tie together many pieces of information in the medical record. But patients rarely have easy access to the notes clinicians write about them. And while patients have the right to review their medical records, including the notes clinicians write, most people generally don’t ask and most clinicians don’t offer.
Visit notes may include commentary, such as:
- What the patient and the clinician discussed during the office visit, including the health problems the patient reports, the doctor’s physical exam findings, diagnosis, and the treatment plan.
- Why the doctor or other practitioner ordered a specific lab test or prescribed a certain medication.
- Other information pertinent to the care plan, such as coordination of care, specific arrangements for caregivers, and non-medical needs.
- What needs to be done after the visit, such as additional tests or studies, follow up appointments, or referrals to a specialist.
“Everything that we have and know about you as a patient, you should have access to.”
Kevin Tabb, MD, President and CEO, Beth Israel Deaconess Medical Center in Boston, MA