Viewing Clinical Notes in Your Child’s Electronic Medical Record (for Parents) (2024)

If you use a patient portal or smartphone app to access your family’s health care information, you may have noticed some recent changes. Notes from the health care provider are now available. This change is due to a national law called the 21st Century Cures Act.

What Is the 21st Century Cures Act?

Part of the 21st Century Cures Act law aims to improve patient access to personal medical information. All health systems must release certain types of health information to the patient portal as soon as it is available. This began with test results and now includes clinical notes.

One goal of the Cures Act is to make it easier for people to see their medical information. This can help parents feel more informed and empowered about their child’s medical care. You could ask for your child’s medical records in the past, but now you’ll see much of this information more quickly because it’s added to the portal promptly.

What Might Be in Clinical Notes?

Looking at clinical notes is new for many parents. Clinical notes will vary depending on the provider, the type of visit and where your child receives medical care.

Clinical notes may include:

  • Chief complaint (CC): The reason your child saw the doctor that day.
  • History of present illness (HPI): A record of your child’s symptoms and when they started.
  • Vital signs (VS): Any measurements taken during the visit, including your child’s weight and height, blood pressure, and heart rate, to name a few.
  • Review of systems (ROS): A series of questions the doctor may ask you (or your child if they’re old enough to respond) to find out what symptoms your child has. This could include how your child is breathing, if they have a fever, feel tired, or have a rash, to name a few.
  • Physical examination: Your provider’s description of what they noticed when checking your child, including how the heart and lungs sounded, how the skin looked, if a body area is tender or swollen, etc.
  • Results: Notes from the doctor about lab results or imaging scans, such as X-rays. The actual test results might be kept in a different place in the portal, but the provider may reference them or interpret them in the note.
  • Assessment or impressions: What the doctor finds to be the cause of your child’s symptoms (the diagnosis).
  • Plan: The doctor’s treatment recommendations.
  • Orders: Information about prescriptions, procedures, tests, referrals to specialists, and follow-up care.

Why Are Clinical Notes Important?

Doctors have always kept notes about each patient’s medical visit. The notes are a record of why the doctor made the diagnosis and recommended the treatments. It captures what conditions the doctor considered and ruled out.

When your child needs to see a different provider, the information gives them a place to start, which can help avoid unnecessary tests and questions. And if you go back to see the original provider, the notes are a good reminder of what happened last time.

What if I Don't Understand the Notes or See Something Surprising?

Clinical notes are intended for health care professionals, so you might not understand some of the abbreviations or terms. You can call the provider’s office with questions or check this list of common medical abbreviations.

You could read something in the notes that is news to you. Some information will be your doctor describing their decision-making process for your child’s care. Remember, doctors must consider all possible causes of symptoms. Some notes might refer to all the conditions they considered before coming to a diagnosis, even if it was unlikely that your child had that problem. They will document why and how they came to the conclusions they did.

For some, reading all the things their doctor thought about may be reassuring. But for others it can feel like too much information. Deciding to read the notes is a personal decision. Just because they are readily available doesn’t mean you have to read them. Sometimes just knowing they are there if you need them is enough.

Also, you may read something that you remember differently about the visit. If so, contact your doctor’s office. You might have misunderstood something, or the office may need to make a correction.

How Can I Use Clinical Notes to Help My Child?

Reviewing the doctor’s notes after a visit can help you better understand your child’s diagnosis and treatment plan. Often, there’s a lot to take in and remember at a doctor’s visit. It’s even harder if you’re distracted by a sick child. Reviewing the notes can be a good reminder of what happened during a visit.

The clinical notes can help you understand:

  • The types of follow-up tests or appointments your child needs
  • The reasons for, dosages, and possible side effects of medicines.
  • Changes in your child’s symptoms or behaviors that you should watch for.
  • When to contact the doctor about changes to your child’s condition.
  • What to do if your child’s condition doesn’t improve or gets worse.
Viewing Clinical Notes in Your Child’s Electronic Medical Record (for Parents) (2024)

FAQs

Should parents have access to their child's medical records? ›

Generally, parents and guardians have the right to inspect their children's records, as long as the records do not pertain to care for which the minor consented or could have consented under law.

Does the HIPAA Privacy Rule allow parents the right to see their children's medical records? ›

227-Does the HIPAA Privacy Rule allow parents the right to see their children's medical records. Yes, the Privacy Rule generally allows a parent to have access to the medical records about his or her child, as his or her minor child's personal representative when such access is not inconsistent with State or other law.

Why can't you look at your own medical record? ›

A physician is entitled to deny you access to certain parts of your medical record, including personal notes and observations; information provided by another party that the doctor agreed to keep confidential; information relating to the treatment of a minor; information the provider believes may cause substantial harm ...

What are the clinical notes of a patient? ›

Basically, clinical notes are a required form of documentation that describes an encounter with a patient. There are many different types of clinical notes, including progress notes, psychotherapy notes, evaluations, treatment plans, and discharge papers.

Do doctors have to share information with parents? ›

According to California law, your healthcare provider can't tell your parents or guardians anything about your exam if you're seen for any confidential services (excluding the reasons listed above). This privacy includes care for problems or concerns in the areas of sexuality, mental health and substance abuse.

Can you see your parents medical records? ›

To be given access, you'll need to be your parents' health care power of attorney or court-appointed guardian. Ask what legal paperwork the office needs to prove that you are your parents' personal representative. Then ask to be walked through the process of setting up proxy access to their patient portal.

For which minor patients are parents or guardians not legally entitled to review health records? ›

The privacy rule, which is based on requirements contained in HIPAA, provides protection against parents' or guardians' access to protected health information for the following circumstances: adolescents aged 18 years and older; emancipated minors; minors who can legally consent to services or receive services without ...

What is the HIPAA privacy rule for family members? ›

The HIPAA Privacy Rule, at 45 CFR 164.510(b), permits covered entities to notify, or assist in the notification of, family members, personal representatives, or other persons responsible for the care of the patient, of the patient's location, general condition, or death.

Who is exempt from HIPAA privacy rule? ›

Some exemptions include: Non-Covered Entities: Entities that are not healthcare providers, health plans, or healthcare clearinghouses, and do not otherwise meet the definition of a business associate, are not covered by HIPAA.

Is it a HIPAA violation to look at your own medical chart? ›

A. No. It is NOT a HIPAA violation to view your own medical record.

Can you see who has viewed your medical records? ›

Can I find out who has accessed my health records? You can request an “accounting of disclosures,” which will tell you everyone who has received your health records for the past six years for purposes other than treatment, payment and health care operations.

Should all clinical data be made available to the public? ›

One of the main concerns is the potential for the misuse of patient data. If clinical data is made public, there is a risk that the data could be used for unethical or illegal purposes. For example, health insurance companies could use the data to deny coverage to certain patients.

What not to include in patient notes? ›

Blame of others or self-doubt, Legal information such as narratives provided to your professional liability carrier or correspondence with your defense attorney, Unprofessional or personal comments about the patient, or. Derogatory comments about colleagues or their treatment of the patient.

What should be recorded in the clinical notes? ›

relevant history and examination findings (both normal and abnormal) drugs, investigations or treatments proposed, provided or prescribed. the information shared with patients. concerns or preferences expressed by the patient that might be relevant to their ongoing care, and whether these were addressed.

What is the difference between clinical notes and progress notes? ›

In other words, progress notes are a subset of clinical notes; they report results of individual appointments, while “clinical notes” include comprehensive patient records.

Should parents make medical decisions for their child? ›

As children develop the capacity to make decisions for themselves, they should be given a voice in medical decisions. Most children and adolescents lack full capacity to make complex medical decisions, however, and final authority to make medical decisions will usually remain with their parents.

Should patients have access to their medical records? ›

The patient or patient's representative is entitled to copies of all or any portion of their records that he or she has a right to inspect, upon written request to the physician.

Can I access my child's medical records in California? ›

Can I access my child's patient records? Yes, but there are exceptions. First, a parent or guardian does not have a right to inspect or obtain copies of a minor's patient records if the minor is legally authorized to consent to their own medical care.

Can my parents see my prescriptions on their insurance? ›

We won't tell your parent(s) or anyone else that you are on medication. As part of regular health insurance communications, your insurance company sends some of your confidential health information—like the services you received and when—to the policyholder of your health plan.

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