Access to notes allows families to manage care across various organizations and helps children become more engaged in their own health.
See also Sharing Notes with Adolescents
Am I required to share pediatric visit notes?
Generally, yes. Clinicians are required to share pediatric notes that are part of a patient’s health record. As of April 5, 2021, all U.S. health care systems are required to electronically share clinicians’ visit notes with patients upon request at no charge. This is required as part of the 21st Century Cures Act program rule on Interoperability, Information Blocking & ONC Health IT Certification.
The 21st century Cures Act in pediatric gastroenterology: Problems, solutions, and preliminary guidance | J Pediatr Gastroenterol Nutr (2021)
Who can access pediatric notes?
It depends on your state’s laws and your patient portal access policies. Parents typically can access visit notes for their minor children, though some organizations limit access to notes for parents once the child becomes an adolescent. Adolescents can also have access to their own notes. They may independently seek “confidential” services, typically related to reproductive health, mental health, and substance use. Notes from these visits cannot be shared with a parent. Laws defining these types of health care services differ from state to state. If appointed as a medical guardian for patients age 18 or older, parents retain access to the patient’s record after obtaining the appropriate court documents.
For more information about adolescent notes, see “Sharing Notes with Adolescents”.
OpenNotes: Sharing visit notes with patients and families | Pediatric Nursing (2018)
What happens in cases where parents are divorced and both share custody?
Most often they both have access to the patient portal. However, a parent may choose to share information privately with a health care professional and request confidentiality from the other parent or the patient. In these cases, clinicians are asked to consider this information sensitive and/or confidential. Such information, however, may not be suppressed in response to formal requests for a copy of the official medical record.
Ethical challenges raised by OpenNotes for pediatric and adolescent patients | Pediatrics (2018)
What happens if the patient is in the custody of Child Protective Services?
If the biological parents have lost custody of the patient, then most likely they will not have access to the child’s account. Some social workers working for certified agencies can register for a patient portal account as the legal guardian. If proper court documents are provided, access can be granted.
Ethical challenges raised by OpenNotes for pediatric and adolescent patients | Pediatrics (2018)
How do patients and families know when a note is available in the portal?
Ideally, your institution has implemented notifications. For example, some health systems send alerts via secure messaging, texts or mobile app notifications that allow patients and families learn when a note has been finalized and is available for review.
