MyChart

MyChart

Starting in November MUSC Health MyChart Users Will Be Able to View Many* Outpatient and Emergency Visit Notes

MUSC Health is now using a program called OpenNotes, which gives on-line access to many of the notes written by your providers.

You may already have a visit note to read in MUSC Health MyChart. Visit notes are in addition to your MyChart Visit Summary.

To see your notes: Log into MyChart. Click the Visits Menu. Select Visit Summaries. Pick your Visit Date. Visit notes will be in the Visit Summary, and you can scroll down to that section.

When you visit MUSC Health, your Care Team will use the electronic medical record to write notes about your condition and your care plan. Your physician, advanced provider, or a nurse on the care team will typically write at least one progress note for each visit. Visit or "progress" notes give a summary to other members of your healthcare team. They tell your provider's observations, tests ordered, and care given during a visit. There may be suspected conditions listed in a note that are not confirmed diagnoses. Although patient education is not the purpose of progress notes, we hope that making this information open for you to read in MyChart will help you to better understand and take part in your healthcare.

*Please note that not all visit notes are automatically shared with patients.

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Index of Clinical Terms

The progress notes your provider shares with you probably have some abbreviations of clinical terms or phrases. These abbreviations help your provider and other members of your care team to quickly write and review each other's notes. Here are some of the more commonly used abbreviations and what they mean.

BMP: BP: C&S:

C/O: CBC: CC: Chem panel:

DDX:

DM: DOE:

ETOH: H&P:

Basic metabolic panel Blood pressure Culture and sensitivity (Used to detect infection) Complains of Complete blood count Chief complaint Chemistry panel (a blood test showing the status of the liver, kidneys, and electrolytes) Differential diagnosis (more than one diagnosis being considered) Diabetes mellitus Dyspnea on exertion (trouble breathing with activity) Alcohol intake history History and physical

HPI: I&D: IMP: LBP: N/V: P: PMH: PRN: R/O: SH: SOB: SQ: T: UA: URI: VSS: Wt:

History of present illness Incision and drainage Impression Low back pain Nausea or vomiting Pulse Past medical history As needed Rule out Social history Shortness of breath Subcutaneous (under the skin) Temperature Urinalysis Upper respiratory infection Vital signs are stable Weight

Questions or Concerns?

If you have questions about a note or result, please ask your provider at your next appointment.

If you feel that health information we have about you is not correct, you have the right to ask us to amend your medical record. Your request for an amendment must be in writing, signed and dated. Please be specific about the record you wish to amend and the reason for your request. The request form is available on the Help? section in MyChart

MUSC Health will write back within 60 days. We have the right to agree to or deny your request. If we deny your request, we will explain why and tell you about your options.

If you do not see any progress notes available, you may put in a request to have them sent to MyChart by going to My Medical Record, click Questionnaires, click Request My Medical Records.

For more information, please contact Health Information Services at 843-792-3881

MyChart* is a registered trademark of Epic systems Corporation.

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