How to read an open note

Below are a variety of notes patients have shared with us over the years, as well as brief descriptions of how they were used by the patient.

After a medical visit, doctors, nurses and other health care providers write notes that summarize important information about you. These notes become a part of your medical record. When a note is shared with you it becomes an “open note.”

The most common way to access your notes is through the online secure patient portal which is hosted by your healthcare provider. Using this secure and free portal, you can, among other things, request appointments, message your health care team, and view your health record, including the notes. If your doctor or nurse does not use a web portal, you can request a digital or paper copy of these records for free. If you are not registered on the portal, contact your provider’s office to find out how to create a portal account.

When I read my note, what questions should I ask myself?

  • Does this note accurately describe the visit?
  • Are the medications, symptoms, and health problems correct?
  • Should I share my note with another member of my care team or family?
  • Is there anything I’m worried about that I want to clarify?
  • Is there anything I don’t understand? Could I get help with understanding medical terms, a diagnosis, or the care plan?
  • Is there information I forgot to share with my doctor, like symptoms or important family history?
  • Are there mistakes in my record that I should follow up on?

Example Notes

These are examples of real notes written by doctors, nurses, or mental health professionals, with descriptions of how each note was used by the patient. These notes are shared with permission. Identifying information has been removed.

Doctors’ notes are written in English. The notes shown here have been translated into Spanish to help you understand what might be in a note. If you don’t read English, you may need to ask a friend or relative who does to help you understand your notes.

How notes look depend on many things, including: who wrote the note, the kind of visit you had, or where you get care. Some are short, while others include a complete description of your visit. Longer notes may include details about your health such as past problems or test results. Some notes might contain material that doesn’t appear relevant. It may be required for insurance purposes or other rules and regulations. These sample notes give you an idea of the information included in medical notes. Think about why it might be helpful to read your own notes.

Download note examples:

Doctor Note: Orthopedic Surgeon

This patient visited an orthopedic specialist to talk about a hip replacement. In this note, the doctor describes the visit and the patient’s symptoms. The doctor also outlines next steps for the patient, including follow-up appointments. The patient used the note to remind himself about the appointments he needed to make. He also shared the note with a family member who helps with his care. Finally, the patient saved the note in a file at home in case he wants a second opinion in the future.

Surgeon Note: Ear, Nose and Throat Pre-Surgery
This patient visited an ear-nose-throat surgeon. To prepare for an operation, the surgeon needed to determine if a breathing tube could be placed in her airway. The note summarized the patient’s medical history and described the surgery to be performed. The note contained difficult medical jargon, including “otorrhea” and “choanae.”
 
The patient said she did not understand those words, but still liked having the note. She used the Internet to look up the terms. To prepare for surgery, she made a list of questions. And she was able to share the surgeon’s note with her primary care doctor at a different hospital.
Social Worker Note: Mental Health

This patient has weekly therapy appointments with a social worker. They talk about the patient’s feelings of depression and anxiety, which worsened after a diagnosis of Parkinson’s Disease. In this note, the therapist describes the patient’s physical and mental health and outlines coping strategies talked about in the therapy session.

This patient was relieved to see that her therapist understands her condition well. Her Parkinson’s is affecting her memory, so being able to look back at the notes helped her remember what she was supposed to do between visits. Additionally, the patient could print the note and bring it to other doctors. Now, all members of the patient’s health care team are informed about her care.

Doctor Note: Managing Chronic Disease
This patient has type-1 diabetes and two other chronic health conditions. She says despite her complicated medical life, she feels healthy. She takes several medications and uses her notes to manage her health.
 
When she picked up her medication at the pharmacy, the instructions seemed incorrect. The endocrinologist involved in her diabetes care is not located at the same hospital where she receives the rest of her health care. This patient printed her notes to share them with her endocrinologist. The notes have helped her feel more like an expert in her own conditions. It’s important to her that her entire health care team has access to the same information.