hematologists/oncologists at the beth israel deaconess medical center before and after open notes. on average, clinicians did not change their note documentation, but for some there were significant changes: roughly equal proportions of clinicians make language simpler and more complex; clinicians who were previously late to submit their note documentation began completing and signing their notes more quickly. a mixed methods study of 13 interviews and a random effects modeling of >500 clinical notes revealed no significant changes in oncology documentation pre- and post-implementation of open notes at vcu medical center (massey cancer center). the interviews revealed oncologists were most concerned that their colleagues documentation might change when they know patients are reading, but this has been unfounded. in a survey of 1,628 clinicians who had a year or more of experience sharing notes (with at least one patient who read a note), 37% of doctors reported spending more time in documentation and changing the way they wrote notes, including documenting sensitive information and changing language that might be perceived as critical of patients. clinicians reading their own notes a study at vanderbilt university medical center (vumc) showed that 42% of employees who view their own medical records directly through the electronic health record (ehr) are using the ehr to view their clinical notes. during the 5-year study period than 28,000 employees were allowed access to their records through the ehr, and 79.4% had logged in at least once. at the time of the study, clinical notes were not shared through the vumc patient portal. patient views of open notes over multiple surveys, people who have experience reading clinician's visit notes continue to report understanding all or nearly all of their notes (93-98%) and find them to be accurate. people who say they do not understand much of a note say they seek out additional information/clarification by using the internet, asking a clinician, or asking a friend or family member. one study asked people with experience reading visit notes if they had suggestions to make the note "more meaningful to patient readers." patient suggestions included: restructuring notes to put the most important information at the top avoiding medical jargon, and/or including “mouse over” features in the online patient portal to define terms and acronyms avoiding potentially judgmental language, such as “patient denies” or “obese” clinical documentation in an open notes environment in one study of post open notes-implementation, 15-20% of clinicians reported making modest changes in their approach to medical records. while changes in documentation are typically small, some clinicians report spending more time in documentation after implementing note sharing. emerging best practices for writing patient-friendly notes include: suggestions examples avoid abbreviations "sob" (shortness of breath) may mean something different entirely to patients. avoid pejoratives such as “non-compliant” and “unreliable” these observations are better off factually documented rather than used to describe a patient. avoid copying and pasting information within the chart patients and other clinicians may be confused by copy and paste. other suggestions: using plain language. signing notes in a timely manner. implementing open notes at health systems sharing notes with patients represents a culture change for clinical practice and may create anxiety or apprehension among clinicians. common questions posed include “how to write/document” when patients are a potential audience for notes, the technical aspects of an open notes implementation as it relates to the electronic health records, and the demands an open notes implementation may pose on the health information management team. after the first year of implementing open notes, uw medicine harborview medical center reported the patient feedback on the transition “involved a large number of patients and notes with few reported problems” and was “uneventful.” ournotes (patient-entered hpi and goals) ournotes, or patient-entered history of present illness (hpi) and goals, is the concept of allowing a patient to contribute to their own medical record by updating their family and social history, writing a concise, structured interval history, and proposing a visit agenda. a component of ournotes may involve a patient first reviewing an open visit note, but it is not a requirement. it has been hypothesized that an ournotes approach may off-load work during a medical visit, free up time for clinicians, and reduce physician burnout, which could prove mutually beneficial for clinicians and patients. ournotes was first discussed in the annals of internal medicine in 2018. an accompanying editorial hypothesized the concept could result in an improved “shared decision making process… thereby (encouraging patients to) follow their physicians’ advice,” and may save health systems billions of dollars on “medication nonadherence.” the opennotes organization received support from the commonwealth fund to further develop and research ournotes. the initial pilot is still being conducted at beth israel deaconess medical center, university of washington, dartmouth-hitchcock medical center, and university of colorado. ournotes in telemedicine as a result of the covid-19 pandemic, beth israel deaconess medical center's pilot of ournotes expanded to telemedicine delivery in mid-march 2020. in an article published in nejm catalyst, a physician recounted how she found her patient's contributions in the ournotes pre-visit process “particularly helpful” before a telemedicine visit, which inspired the research team to modify the ournotes form as tool for telemedicine. the modified form can be downloaded from the paper, covid-19 as innovation accelerator: cogenerating telemedicine visit notes with patients. the form is creative commons attribution 4.0 international (cc by 4.0). “e-patient” dave debronkart blogged about his experience with ournotes for telemedicine, saying the telemedicine visit was made easier “by being given a structured way to prepare for my visit.” health systems sharing visit notes with patients more than 44,000,000 patients have access to clinical notes at 210 health systems in north america. in 2013, the u.s. department of veteran's affairs (vha) introduced an enhanced version of its blue button personal health record, including access to clinical notes. related u.s. public policy the 21st century cures act, passed by the u.s. congress in 2016, requires patients be offered access to all the health information in their electronic medical records without charge by the provider, including the notes their clinicians write. in 2020 the office of the national coordinator for health it published the final program rule for the cures act on interoperability, information blocking, and onc health it certification mandating that clinical notes be available on request, in a format the patient wants. how and when this rule will be enforced is in the process of being clarified.