What “Open Notes” Means for Therapists (for now)

This post is courtesy of Laura Groshong of the Clinical Social Work Association.  I know Laura from a NASW task force, and let me tell you, this lady knows her stuff!  She sent this info out to the CSWA and graciously gave me permission to reprint it here.

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You may have been hearing about a new rule that is called “Open Notes” which begins on November 2, 2020. It allows patients to have extended access to their Medical Record.

While it is technically true that patients have increased access to their electronic clinical records as of November 2, it should not be much of a change for the way we as LCSWs practice with one exception (see below).  Open Notes was part of the Interoperability section of the CURES Act last spring which says:

Blease C, Walker J, DesRoches CM, et al. Annals of Internal Medicine. October 13, 2020. doi: 10.7326/M20-5370

On 2 November 2020, new federal rules will implement the bipartisan 21st Century Cures Act that, in part, “. . . promotes patient access to their electronic health information, supports provider needs, advances innovation, and addresses industry-wide information blocking practices.” The rules forbid health care organizations, information technology vendors, and others from restricting patients’ access to their electronic health care data, or “information blocking.” Although the Health Insurance Portability and Accountability Act gave patients the legal right to review their medical records, the new ruling goes further by giving them the right to access their electronic health records rapidly and conveniently via secure online portals. Providers must share not only test results, medication lists, and referral information but also the notes written by clinicians. Over the past decade, this practice innovation—known as “open notes”— has spread widely, and today more than 50 million patients in the United States are offered access to their clinical notes.”  https://www.opennotes.org/research/new-u-s-law-mandates-access-to-clinical-notes-implications-for-patients-and-clinicians/

I believe that Open Notes is primarily for other kinds of medical services, not psychotherapy.  The only exception may be if we are not making notes in the interoperable medical record. There may come a time when other providers or patients complain about it and we will need to make “open notes” in an interoperable record, but that is not the case now unless you are paneled in a plan that requires you make notes in an interoperable record. 

Remember that Psychotherapy Notes can be a separate file from the Medical Record which is for our use only, most commonly what we call process recordings, and are not shared with anyone else.  There is certain information which cannot be kept out of the Medical Record by being put in Psychotherapy Notes; see the CSWA website for more information.

We know that it is a clinical issue if the patient wants to see what we have written about them and it happens fairly rarely.  We also know that it is a best practice whether we are keeping notes for our own Medical Record or an interoperable one, to keep notes brief and connected to the treatment goals established for a given patient. If we stick to these practices, Open Notes should not pose a problem for clinical social workers.

Laura W. Groshong, LICSW, Director, Policy and Practice
Clinical Social Work Association