A few days ago, I went for my annual physical and within hours, my physician’s charting of the exam was available in my online patient portal. Laid out for the first time after one of my medical visits was Dr. Tameron’s* clinical view of my innards as well as my cognitive presentation – everything from “normal bowel sounds” “no rash” “appears well-nourished” to “appears stated age” and “normal judgment and insight” was available for me to see.

I had access to this electronic baring of my doctor’s notes as a result of the 21st Century Cures Act – namely “interoperability, information blocking, and the Office of the National Coordinator for Health Information Technology’s final rule.” As of April 5, 2021, this federal ruling requires all healthcare providers to grant their patients secure and free access to nearly all of their electronic health record (EHR) information. See OpenNotes for more details.

There are many factors to consider in the arena of shared note access when it comes to one’s physical health – imagine, for instance, patients finding out from a scan of their online chart that they had a disorder before the clinician had a chance to relay the news verbally? When it comes to behavioral and mental health care (our milieu), what does full transparency look like? Indeed, in what way (if any) should our patients having access to our clinical notes impact how we write them?

Cures Act Application to Psychotherapy Notes

The Cures Act mandates the sharing of mental health records including diagnosis, treatment plan, symptoms, prognosis, progress to date, medication monitoring, functional status, and “progress notes.” The latter are considered the “official” record of each therapy session and meant to be seen by each member of the treatment team. Progress notes include specifics such as dates and times of services, assessments, intervention plans, and consent forms. This makes sense. Patients should have access to these details.

My apprehension over shared access falls under the area of “process notes.” This is the clinician’s subjective view of what happens in a particular session and contains impressions and details of the conversation.

As a psychotherapist (versus a psychiatrist who makes diagnoses and prescribes medications), after the initial session where I do a detailed intake, the process note is the primary focus of my charts. Perhaps because I transitioned from a career in publishing – which called for descriptive and sometimes emotional prose – to working as a psychotherapist where the writing style is flat, neutral, and 100% clinical, the process note can be a bit of a bete noir. My notes use minimal jargon – “normal judgment and insight” and “normal mood/affect” – and are void of purple prose, yet occasionally veer into judgments and concerns that I fear if seen by the patient might impact treatment, such as “Her over-the-top tendency to wallow in self-pity provokes a virulent counter-transference in me.”

While the Cures Act ruling does not apply to “psychotherapy notes” – as long as they are stored in a separate area of the medical chart  – and pertains solely to electronic notes, I nonetheless joined an EHR platform in March 2021 to see how it worked. This was after well over a decade of keeping notes the old-fashioned way – that is, barely legible hand-written scrawls in manila folders identified only by my clients’ names. I’ve decided to stay with the EHR because it is less cumbersome to maintain, though I’m now even more cautious about my notetaking.

Clinical Documentation: To Expand or Retreat

So where do I go from here? Over my nearly 14-year-career as a psychotherapist, I  have tussled with how detailed or opinionated my notes should be. Overall, I’m grateful no private patient has ever asked to see his or her chart. They seem oblivious to the Cures Act, which obviously suits me. If someone does ask, I will explain truthfully that my notes are not overly detailed and we can discuss whatever they wish to know about my impressions of them.

Note-taking is more of a minefield at my freelance job at a nonprofit mental health care clinic which primarily services patients with substance use disorders and severe mental illness, most of whom are also under a psychiatrist’s care. The clinic’s charts are frequently audited by the state, so therapists’ session notes are augmented by a constant stream of documentation, including psycho-socials, treatment plans (which were signed by the patient in pre-pandemic days), vaccination updates, occasional incident or report forms, etc. I always adhere to my supervisor’s advice to “chart the facts” – for instance, “Patient reports no impulsive episodes” versus any perceived declarations that could embroil the clinic in legal cases.

Now that the stakes are higher at the federal level, curiosity over how other behavioral and mental health clinicians share my apprehension about revealing notes to patients has led to intense conversations with colleagues, and ultimately this article.

Therapists Give Open Notes Policy Mixed Reviews

Here’s what a few colleagues had to say about the impact of the Cures Act on their work.

Katie Lear, LCMHC, RPT, RDT, who specializes in childhood anxiety and trauma treatment, is supportive of sharing notes with patients. “I occasionally have teen clients who are curious about the notes I’m jotting,” explains the North Carolina-based practitioner. Lear sates this curiosity by sharing her computer screen with the teen, even sometimes writing a note together. Lear laughs, “Usually after they’ve seen it once, they’re no longer interested – it’s not that exciting.”

A more mixed review of the Cures Act is held by Alexandra Emery, PhD. An early career psychologist at Grit City Psychology in Washington state calls her note-taking practice “evolving,” as is her opinion of note sharing. Dr. Emery, a master clinician of 5 years standing, says, “I document suicidality, mood, self-orientation… but not in enough detail that if someone gets ahold of the note he or she will know that much.”

Dr. Emery muses, “Notes can provide a client with an accurate representation of a session but also open up a lot of questions…” The practitioner adds, “Uh, did the people who came up with this law see patients?”

Sloan Smiloff, PhD, has no equivocation about where she stands on open notes. The New Jersey-based psychologist says, “No f-ing way do I share my notes with a patient … or even other doctors. Mental health is very different from physical health. You don’t say, ‘I am my liver.’ But you might say, ‘I am my bipolar diagnosis!’

Dr. Smiloff admits that the notes she keeps for someone who is borderline, schizophrenic or has another severe mental illness are not analogous to those she writes for a highly functional patient. These patient notes are much more clinical.  On the other hand, she shares, “If a longtime patient with situational depression is primarily seeing me for love and emotional support, my notes might have ditto marks running down on the page. Or if it’s someone who is emotionally draining me, I might be writing three times in a row ‘I hope she cancels next week.’”

According to Laura Groshong LICSW, “If a patient trusts us, he or she doesn’t generally feel the need to see what we write. When a patient asks to see notes, the treatment alliance is shaky and seeing the notes likely won’t resolve anything.”

Groshong, who directs policy and practice for the Clinical Social Work Association out of Seattle’s headquarters, seconds Lear’s tactic of going over the notes with the patient. “Reading the records together can help the patient understand what he or she is reading into it. This can then be made part of the treatment.”

She believes the Cures Act is aimed more at medical versus psychological records. “Say a gynecologist notices there’s a benign cyst and puts in the record: “Check this in 6 months for carcinoma” but didn’t mention anything to the patient. People have a right to know about this basic stuff but that is very different from what mental health care clinicians do.”

However, she points to the benefit of the Cures Act in reminding clinicians that it is important to think about what we decide to put in the medical record. She says, “What we write shouldn’t be based on the fact that the patient can access it. Everybody who can access the records should have a limited amount of information about the treatment: goals and how the treatment goals are being met. That’s a pretty limited set of information.”

Groshong sees more added value in sharing information between colleagues who may be involved in a particular patient case. Verbal sharing in the interest of helping the patient, that is. “We don’t talk to each other as much as we could,” she says.

Back to Reality: Open Notes in Practice

A recent poll of an international panel of experts on the potential impact of the Cures Act on psychiatric treatment found that “patient autonomy in mental health contexts must be balanced with the potential benefits and risks to patient care.” What this means for the future of mental health care practice is yet to be determined. What’s your take? Email the editor.

For me, while I’d personally rather not have the Cures Act apply to mental health care clinicians, I am grateful to now be more mindful of my charting and to know that the greatest knowledge about my patients will always be free from inquiring minds and eyes – that is, in my head.

 *Name changed

 

Last Updated: Jun 25, 2021