A medical record is a comprehensive history of the care a patient receives, documenting everything from initial symptoms to final treatment outcomes. This record is the official legal and clinical file maintained by a healthcare provider. A common question concerns the documentation created by the doctor during a visit—the “notes”—and whether they are included in this formal record. The short answer is that a doctor’s notes are a fundamental component of the official medical record. These notes are the written evidence of the provider’s thought process and the medical decisions made during the patient encounter.
Essential Documentation Included in Records
The vast majority of documentation generated by doctors is considered part of the legal medical record and is accessible to the patient. These documents are collectively known as the “Designated Record Set” under federal law. This set includes all medical and billing records maintained by or for the healthcare provider, and the information is used to make decisions about a patient’s care. The notes serve as the official, chronological account of the patient’s health status and treatment journey.
Doctor-generated notes follow standardized structures to ensure clarity and completeness for other care providers. Common formats, like the Subjective, Objective, Assessment, and Plan (SOAP) framework, organize the information into distinct sections. Progress notes, which document the patient’s condition and treatment plan during follow-up visits, are a core part of this record. Other standard documents include history and physical examination reports, operative reports, and discharge summaries created when a patient leaves a hospital.
The inclusion of these notes ensures continuity of care, allowing any provider who accesses the record to understand the patient’s context and past treatment decisions. This documentation provides the necessary clinical narrative to support the diagnoses and treatments listed. The documentation is both clinical and legal, forming the basis for billing and compliance with regulatory standards. A patient has a legal right to access this complete Designated Record Set, including all clinical case notes.
Notes That Are Excluded From Patient Access
While most doctor-generated documentation is available to the patient, specific, legally defined exceptions exist where notes may be excluded from mandatory patient access. The primary exception centers on “Psychotherapy Notes.” These are defined as notes recorded by a mental health professional documenting or analyzing the contents of a private, group, joint, or family counseling session.
To qualify for this exclusion, these notes must be kept completely separate from the rest of the patient’s medical record. They are intended to be the therapist’s private analytical tool, reflecting personal impressions, hypotheses, and reflections, rather than the clinical facts used for treatment. Information that must be included in the standard medical record is explicitly excluded from the definition of Psychotherapy Notes. Routine mental health notes, treatment plans, and diagnostic summaries are fully accessible to the patient.
A provider may also keep private, non-clinical “Personal Notes,” which are not legally required to be shared. These might include informal reminders or speculative thoughts not used to make decisions about the patient’s care or treatment. Since these notes are not part of the Designated Record Set, they fall outside the federal right of patient access. However, any information used to make a decision about the patient’s care must be included in the official record and is therefore accessible.
How Patients Can Request Their Medical Records
Patients have a legal right to access their medical records, including all standard doctor’s notes, under federal law. This right does not require the patient to provide a reason for the request. The process typically begins with submitting a written request to the healthcare provider or facility’s medical records department. Many providers also facilitate access through secure online patient portals, which often allow for instantaneous viewing of records and notes.
Once a request is received, the healthcare provider must act on it promptly and is legally required to provide access to the requested information within 30 calendar days. If the records are archived off-site, the provider may extend the response time by an additional 30 days, but the patient must be notified of the delay in writing. Providers may charge a reasonable, cost-based fee for copying and mailing the records. State laws can mandate a shorter response time or prohibit fees for accessing personal health information, taking precedence over the federal requirements.