Open Notes Module Enables Portal View of Encounter Notes

On April 5, 2021 the 21st Century Cures Act federal rules on Open Notes take effect. The new rules require that healthcare providers give patients/clients immediate access without charge to all applicable health information in their electronic medical records. Some organizations may not be aware of this requirement due to the focus on COVID-19 over the past year. The following types of notes must be shared with patient/clients:

• consultation notes

• discharge summary notes

• history & physical

• imaging narratives

• laboratory report narratives

• pathology report narratives

• procedure notes

• progress note

The new rule does not apply to many mental health records and there are also standard exceptions that can be used by providers to "block" a specific record from being shared. Providers need to specify which of the exceptions they are using if they "block" a record in the event that a patient/client challenges this decision. PNC introduced an optional "Medical Records" module for the OpenCommunicator patient/client portal several years ago. To date, the Medical Records module allows patient/clients to see their lab reports, radiology reports, problem list, allergies/medications and procedure list. For patient/client visits, only the date/time, provider and department have been displayed. To meet the rules in the Cures Act, PNC has enhanced the Medical Records module to support displaying the full content of a visit note on the portal.

New settings allow note sharing to be turned on or off by department and by visit type.

There are new fields in the chart note that allow a provider to "block" an individual note from the portal by specifying one of the allowable exceptions and to add text details as needed.

A webinar with additional details of this new module and instructions for setup will be available soon. PNC sites that already have the OpenCommunicator and Medical Records module licenses will be able to activate the new Open Notes feature without charge unless they require PNC assistance for setup, which will incur a setup fee. If you do not have either of these modules and are interested in enabling them, contact the PNC business office by opening a Zendesk support ticket. We anticipate many sites will be enabling these modules, so if interested, please apply early to get in queue. Here are some helpful references to learn more about the Open Notes rules:

• Federal Rules Mandating Open Notes

• Cures Act Final Rule: Information Blocking Exceptions