The implementation of Open Notes in Sweden, granting patients access to their clinical records, has been a complex and nuanced endeavor, marked by regional variations in strategy and challenges arising from the diverging needs of healthcare providers and patients. This paper presents an interview study with managers about the implementation process in five of the 21 regions in Sweden. The aim of this study is to explore the experiences and strategies of these managers in navigating the implementation challenges. The study sheds light on the prevalent theme of uncertainty throughout the implementation journey and the strategies used to balance conflicting perspectives. The findings contribute to our understanding of Open Notes implementation and offer policymakers and healthcare organizations insights about enhancing the implementation process to optimize patient care.