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Frequently Asked Questions

Clinical Notes in MyChart

 

To make sure you don’t miss important information about your health care, UW Health has added a new feature in MyChart that allows you to review details of your visit, as captured by your provider. Shared notes can help make sure that you and your healthcare team are on the same page.

 

What is a Clinical note?

 

After a visit with your doctor, nurse or other health care professional he or she writes a note that reflects the visit, summarizing the most important information. The note becomes a part of your medical record and may contain:

  • A summary of what you told the doctor or nurse, also called a history
  • Findings from an exam, such as your blood pressure, weight or how your lungs sounded
  • Lab, radiology, pathology or other test results
  • Your doctor’s assessment or diagnosis of any medical conditions or symptoms, also called assessment or impressions
  • The treatment plan recommended by your doctor and discussed with you
  • Next steps, including upcoming tests, follow up appointments or referrals

This is different from, but complements, the visit summary UW Health already makes available in MyChart.

 

When will notes be available for me to view in MyChart?

  • September 25, 2018. Notes before this date will not be available via MyChart, however, you can always request copies of your medical record from the UW Health Information Management team. Learn how to obtain your medical records

Will all of my notes be available?

  • No, while notes form most outpatient visits will be displayed in MyChart, notes from admissions or hospital outpatient departments are excluded at this time
  • Notes written after September 25th will be viewable

What are the benefits of reading your notes?

 

Patients who read their notes report that they:

  • Have a better understanding of their health and medical conditions
  • Can better recall and follow their care plan
  • Feel more in control of their health
  • Take better care of themselves
  • Do a better job taking their medications as prescribed
  • Can identify inaccuracies in the record and play a role in the safety of care
  • Feel comfortable sharing notes with care partners and others involved in their care
  • Can communicate more clearly, helping to strengthen the partnership between themselves and their health care team

How can I get the most out of my notes?

  • Read your notes after a visit to carefully review what was discussed
  • If there are terms you don’t understand, look them up, or ask your clinic for reliable websites or other resources to learn more about your medical conditions
  • Review your note to make sure the information is accurate and up to date. Let your doctor or clinic know about any changes that should be made to ensure the safety of your care.
  • Read notes between visits to remind yourself of the treatment plan and to remember upcoming procedures, tests, or appointments
  • You may decide to share your note with family, informal caregivers, or others who are involved in your health. Sharing is a great way to help manage care and to make sure your entire care team is on the same page.
  • When you read the note, it may trigger questions or remind you of additional information potentially important for your care. Try to take the appropriate action. Some issues can wait for a next visit; others are best addressed quickly.
  • Share your notes with other healthcare providers outside of the UW system

How do Clinical notes affect confidentiality and privacy?

 

It’s important for you to know that clinical notes do not change the confidential relationship you have with your health care team. What does change is your ability to share. With clinical notes, it’s easier to share your medical information with a care partner, family member, or others, but only if you choose. You are in full control of who has access to your note, which means you are in full control of your privacy.

 

If I have designated a proxy (someone else who has access to my MyChart account), does that person have access to my notes?

  • Yes, notes that display in your MyChart will also show for your proxy
  • If you are proxy of an adolescent (age 12-17), notes will not display

What do I do if I notice an error in my note?

 

If it’s a serious issues, like a potential mistake that could affect your care immediately, contact the UW Health Information Management team (608) 203-1440, or submit a UW Health Request of Amendment of the Medical Record form. For other inaccuracies, use your best judgement if it can wait to be brought to the attention of your treatment team during your next visit.

 

What do I do if I am looking for a note written after September 25, 2018, but that note is not available in MyChart?

  • Notes will not be available immediately after your visit. Some providers may take a couple of days to complete their note.
  • Not all notes will be viewable in MyChart. If you would like to see any of your record that is not available in MyChart, you can request it using the Obtaining Medical Records form.

Why do my notes look different from one note to the next?

 

Each provider has their own style of writing notes. You are seeing the note written exactly as the provider wrote, which may vary from provider to provider and from visit to visit.