21st Century Cures Act Mandates Health Care Providers to Share Clinical Notes

August 13, 2021

While the Health Insurance Portability and Accountability Act, commonly known as HIPAA, still governs the sharing of medical information to protect patients’ privacy, the newly passed 21st Century Cures Act now requires 8 new types of clinical notes to be provided to patients and approved persons under HIPAA.

On April 5, 2021, this new federal law was passed requiring the following 8 types of clinical notes to be shared:

- Consultation notes

- Discharge summary notes

- History and physical

- Imaging narratives

- Laboratory report narratives

- Pathology narratives

- Procedure notes and

- Progress notes.

There are a few notable exceptions. Mental health professionals are not required to disclose mental health notes. Any information compiled in reasonable expectation for use in a legal matter such as a criminal or civil hearing does not have to be disclosed under these rules.

The patient is given access to these clinical notes as well as anyone the patient authorizes. The patient can authorize someone to receive information if the patient is awake, has a reasonable understanding of the situation and has the opportunity to refuse. If the patient is not awake or has some type of cognitive impairment, then only those granted access through an advance medical directive or a HIPAA waiver signed while still competent can provide access to the clinical notes and other medical information.

The purpose behind the law is to increase the transparency of treatment. Family members gain more insights into the doctor’s thoughts and medical decisions by reviewing these types of clinical notes. It helps to aid in deeper discussions and allows for more clarification. Caregivers and family members who review these types of clinical notes typically develop a better rapport with the health care providers which results in better overall care, attention and follow-up.

If a medical provider refuses to provide these clinical notes, the U.S. Department of Health and Human Services can by notified via its website. A patient or authorized person can file a blocking report. Health care providers have until the end of 2022 to upload this information to third party apps and portals that provide access to health care information online.

To get started on estate planning that includes advance directives and HIPAA waivers contact the experienced and compassionate estate planning attorneys at Stouffer Legal in the Greater Baltimore area. You can schedule an appointment by calling us at (443) 470-3599, emailing us at office@stoufferlegal.com, or register for an upcoming free webinar using the link below:

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