Doctor’s Chart Notes

Has anyone seen their doctors notes on them. I have some from when my wife was younger and some more recent stuff.

When her family doctor retired she was able to get copies of all her file. We had tried to get them earlier but he would not let us have them. This was many years ago. Now most doctors would give you some sort of redacted version of what they wrote.

When she was a teen he often commented on her appearance. Sort of clinical but not completely.

He once said, “...an attractive young woman developing normally. Well groomed and alert.”

When she was younger he would put in a code that I think must be the way they gauge sexual development and physical development. And he often made some comment about her ‘development.’

Once she saw a back doctor who wrote back to her family doctor.

He said, “Thank you for sending this young woman for me to examine.”

“As you know she will be a junior in high school this fall. She presents as a lean young woman demonstrating normal development.”

And at the end he wrote, “It was a pleasure to examine this young woman. Thank you for the referral.”

Has anyone ever seen anything interesting in their doctor’s chart notes?

I read records all day long. I do see notes about a patient's appearance, but I've never seen any describing a patient as attractive. Pleasant, yes, attractive, no. I'll see well groomed and alert, developing normally, and so on, but never that. General appearance is assessed routinely, as that can give a clinician a very big tip off if all is not well.

It's not uncommon for consult notes to finish with something akin to ‘thank you for sending me this patient’ or ‘thank you for being able to participate in this patient’s care', but not phrased exactly like that that I've seen.

Non medical background here - but aren't you entitled to ALL medical records (of yourself or another consenting patient) if you request them? I would think anything a Doctor writes down would be subject to disclosure with a simple “Release of Medical Information” request.

Yes, gwhap, i believe you are right. now you can easily get your records. but when we first tried 30 years ago it was very hard.

Yes, not only can you get access to all of them, if you have access to your electronic medical record through a patient portal, you have immediate access to notes and also lab results in real time (at the same time they become available to your provider.

Wow, very interesting to see the language that they used. I can't seem to access any of my medical notes in the portal. It just contains my lab results.

It’s rare that you can see everything via the patient portal. Request the paper records and you can see much more. Sometimes you have to be very specific in what you request or they’ll just release the basic SOAP visit summary which won’t always include all their notes.

Yes I can see my exam notes and the summary reports on the portal. As well as the labs and imaging. As for his notes he talks them into the computer as he goes they are as he enters them. So are my vitals they entered as soon as the nurse has taken them.I have read my other notes and reports some of which I don't understand. I have had to call and have some stuff explained to me.

It’s rare that you can see everything via the patient portal. Request the paper records and you can see much more. Sometimes you have to be very specific in what you request or they’ll just release the basic SOAP visit summary which won’t always include all their notes.

Yes I can see my exam notes and the summary reports on the portal. As well as the labs and imaging. As for his notes he talks them into the computer as he goes they are as he enters them. So are my vitals they entered as soon as the nurse has taken them.I have read my other notes and reports some of which I don't understand. I have had to call and have some stuff explained to me.

As far as I know, everything goes in the computer and I have access to it via our portal - My,chart. I’ll ask my doc if she keeps any private notes, doubt that she does. Nice thing with labs it shows upper/lower bounds and flags anything that breaks them. We can graph their history ove time.

I'm glad some members can access their notes via patient portal. I've asked the medical practice where I am registered a couple of times to fix it up for me to see my notes through the appropriate app on my phone. They said 'yes' and then nothing happened.

I've probably got the right legally but I'm not very motivated to do that. I don't feel strongly enough.

A couple of years ago, my general practitioner had to leave the room for 2 minutes or so during a consultation. He left the screen open so I used the opportunity to read it. I didn't feel I had the right to scroll down. From what was on the screen, the software included the current appointment and the last one. All he'd written was '? sun damage on exposed scalp.' I'd gone in to query a lesion on my bald head. The last appointment was a diabetic annual review I'd been to by one of the nurses. There were boxes with all the standard measurements and 1 short sentence about my diabetes being well controlled. Very dull.

I WOULD like to look back over notes from a few years ago - just to see if the doctor's notes matched my memory. And notes from my childhood for times when I was taken by my parents. Not sure f those records are still there. They should be but 50+year old records would be hardcopy.

It’s not uncommon for a provider to keep private notes about patients that they view as “problem patients” “special patients” those that are delinquent in paying bills, attention seeking patients, patients who are non compliant with treatment, patients who they feel they don’t enter the room without a chaperone, drug seeking patients, etc etc etc etc. They also have ways to flag records and charts that the patient will never realize. This may also include mental health notes, psychological and psychiatric if they are in the medical records.

If a patient/client is meeting with a mental health professional: Psychological and psychiatric patient notes… That is a completely different animal when it comes to getting copies of chart notes. It can vary greatly from one therapist to another, practice to practice all in accordance to state law. Many won’t release any chart notes directly to their patient/client without a court order. Those court orders are required to be extremely specific as to the information they are demanding to be released.

@Fawkes Dependent on jurisdiction. I think in France they cannot legally refuse to hand notes to patient, but I may be wrong.

Your mention of "unofficial" marks and notes about special patients reminds me of an episode of, I think, Inspector Derrick, where a doctor provides illegal abortions and uses special marks to denote them.

@Fawkes Dependent on jurisdiction. I think in France they cannot legally refuse to hand notes to patient, but I may be wrong.

Your mention of "unofficial" marks and notes about special patients reminds me of an episode of, I think, Inspector Derrick, where a doctor provides illegal abortions and uses special marks to denote them.

@Fawkes Dependent on jurisdiction. I think in France they cannot legally refuse to hand notes to patient, but I may be wrong.

Your mention of "unofficial" marks and notes about special patients reminds me of an episode of, I think, Inspector Derrick, where a doctor provides illegal abortions and uses special marks to denote them.

@Pecan_nutjob,

I would be surprised if things didn’t vary from jurisdiction to jurisdiction in states, countries etc. There are countless subtle ways to flag patient charts/notes and hide things from their view.

@Fawkes Sure. You can't explicitly write down things such as "makes female staff uneasy with the way he looks at them", "hypochondriac" and so on.

I would be surprised if things didn’t vary from jurisdiction to jurisdiction in states, countries etc. There are countless subtle ways to flag patient charts/notes and hide things from their view.

@Fawkes I’m no expert on this, but isn’t anything charted and shared between doctors/insurance accessible to the patient? I know doctors have opinions about patients and definetly keep mental notes, maybe even unofficial private notes that aren’t in your medical records. Good example is alcohol. They will chart how much you say you drink, but mentally add a factor to it if they have reason to think you’re not truthful. Or if you claim you’re diligently taking your meds and they suspect not - they can’t chart some of these hunches due to liability issues, they only chart what is observed or what you tell them

At first I thought you were off-base, but the more I think about it, they probably do have “off the record” notes. I’m just guessing those observations are not in the official records, and not available to the patient, while still being compliant with the laws.

In the U.S. just about two years or so ago, as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), any provider who accepts Medicare payments for services were required to make any notes made in a patient's chart available to that patient via a patient portal, unless it would be a detriment or safety risk to the patient. This includes physicians notes, nurses notes, test results, etc.

I'm glad some members can access their notes via patient portal. I've asked the medical practice where I am registered a couple of times to fix it up for me to see my notes through the appropriate app on my phone. They said 'yes' and then nothing happened.

@Cefn atleast they offered. I got so frustrated trying to set up my sub's but after numerous failed attempts, the passwords I was trying to use show that, I gave up. Doctor offices would like that you sign up for appointments through "My Charts" but don't bother to assist you in that process. Even when you mention the trouble.

I’ve gone online after an office visit and read the visit summary. Frequently the doctor misinterpreted what I said. Usually it seems like they are putting down comments that cover their butt. They clearly want to have an entry for each billable topic.

Most of my practice years were in the age of handwritten chart notes. The only typed notes were dictated in the hospital and for consultations. The laws about making medical records available to patients vary from state to state but probably less now than in the past. I would give a patient his/her chart if they were moving or going to a new doctor. I don't know of any doctors who kept second charts but it could have happened. As to actual verbiage, we all (in my day) learned to begin the history with a comment about appearance. We used to laugh about how many letters we could start with. WDWNSWF would be well developed well nourished single white female. And finishing or beginning a consultation with the flowery "thank you for allowing me to see this pleasant gentleman" was pretty standard.

I have access to most of my records online, though they changes platforms at one point and I'm not sure of visibility of older records now. They include the standard notes of what we talked about / examined and the general results. I feel that it's a quick synopsis after the exam, so not the exact conversation or all the details. The note that sticks out the most was clearly in regards to me getting an erection during the first exam. On my initial questionnaire (scanned in), next to the sexual health check boxes, near the erection difficulty area, there was a big nope written in.

I liked reading the medical notes from my colonoscopy. It was interesting to read what all happened and at the end he said it was a pleasure to serve this pleasant man or something.

I saw an ENT a couple of months ago. When I read his notes about my visit, there were comments about my normal looking tonsils and adenoids. The only problem I saw was that my adenoids were removed when I was 6 months old and my tonsils were removed when I was 4.

I went to a well-known pathologist, who misdiagnosed me. Then he followed up with what I considered to be invasive and subjective questions about my personal life. When I went to get another opinion, the 2nd doctor ruled out the initial diagnosis, and was not willing to discuss the original doctor’s findings with me. He was trying to protect himself from liability.

I saw an ENT a couple of months ago. When I read his notes about my visit, there were comments about my normal looking tonsils and adenoids. The only problem I saw was that my adenoids were removed when I was 6 months old and my tonsils were removed when I was 4.

@Srgfgahs You must be part Salamander - with regenerative organ growth!!!! 😄😄

So are the appearance comments just for children? I'm 33 and my doctor always notes her views of my appearance, clothes I'm wearing, etc.... My friend also goes to her and never gets any comments on apearance. She also talks to me like a child, so.....

So are the appearance comments just for children?

I don't think that's so, and am of a close age to you. I get notes of general appearance and cleanliness, though not necessarily what I'm wearing. Though if you're getting unfair treatment and judgement, sounds like it's time for a new doctor.

The language in medical records as pointed out by Pollux tends to sound pretty standard especially if you were referred to a specialist by your GP. Mr. or Ms. ____ presents as an attractive, alert young man or woman. There is usually a sentence at the beginning or end for the referring physician thanking them for sending the patient. It's usually harmless. I was once an attorney in an insurance defense firm and read hundreds of these things. After awhile they all sound alike. But be careful about medical records. If you ever file a personal injury lawsuit, the defendant will do a discovery request for any and all records from every doctor or medical facility you ever visited. Yes, they are confidential, but they have a right to see that your screwed up back was actually a pre-existing condition that you had treated before. For that reason, it is important to review medical records occasionally. Make sure they correct any errors because it could hurt you later. I've done it whenever I change GPs. A few years ago I found several errors on my chart. One was that I had had hepatitis. Not true, and no idea how that wound up in this doctor's notes. Prior to his retirement I could tell he was not feeling well. I wrote a letter pointing out that and a few other minor errors, and they corrected them. As for odd questions, I used to live in NY State, and there was a "safety" questionnaire doctors used. Do I own a gun? Really not my doctor's business. Do I always wear a seat belt? Good question, but who would say they don't? Think only your doctor will see that? Don't count on it. Loved NY but also love my privacy. I am careful now to keep the conversation with doctors very factual and don't offer anything unless I think it needs to be added.

I have access to all of my records from all of my doctors. All of the doctor’s personal notes are spot on from what transpired in the exam room

I can view the exam notes electronically after every visit.