Reading mental health notes can be a powerful tool in therapy.

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Between now and the April 5 federal mandate of the implementation of the 21st Century Cures Act Info Blocking Rule, we’re answering your top questions about the open notes aspect of the rule.
In several studies of how open notes affect the way doctors prepare notes, the majority report they don’t change the way they write their notes. But many clinicians experienced in sharing notes report their writing does change over time, feeling overall that it becomes more valuable, certainly to patients. Few report “dumbing down” their language, but they find themselves using fewer abbreviations and trying to avoid language that could appear judgmental to patients. Some report modulating their practice such that they become “teaching notes.”
In general, patients do not expect doctors to write notes in layperson language, and more than 90% in one large study report understanding their notes well. Patients not bothered by terms they don’t understand, and they are happy to research terms. They feel reading notes helps them prepare more focused questions for clinicians. Overall, they express considerable enthusiasm for having a window into more information about their health.
Resources:
Tip Sheet: Suggestions for implementing open notes in clinical practice, OpenNotes.org
How to write an open note for patients, CT Lin, MD
Under the new federal mandate, in certain specified situations information can be blocked (or “hidden”) from patient access on online portals—these are called Exceptions. As examples, clinicians can block notes
• If they believe a patient will harm another person or themselves as a result of reading a note
• If they need to protect the security of another person’s electronic health information (e.g., a mother’s health information in a child’s record)
Unless one of the Exceptions applies, clinical notes must not be blocked. Details about exceptions are outlined at HealthIT.gov.
Learn more about how the Cures Rule applies to open notes.
We’ve spent more than 10 years studying the effects of open visit notes on patients, care partners and clinicians. Time and again, studies show that open, transparent communication through visit notes are a good thing, across all demographics, and the majority of clinicians with experience with open notes feel it is a good idea and would recommend it to colleagues
This website serves as the “library” of the OpenNotes movement. You are likely to find many answers to your questions if you take a little time, review a newsletter, or sign in to one of our past or future webinars. In addition, several places on this website detail research and best practices about open notes in special circumstances. Check them out.
In advance of open notes, clinical staff more often than not anticipate significant changes to workflow and workload. However, time after time we hear such worries proved misplaced. Among the >260 organizations that implemented open notes prior to November 2020, not one reported a significant increase in visit time with patients or in e-mail traffic. In fact, some reported a decrease in e-mail, as patients are able to resolve confusion or forgetfulness by reading their notes.
Patients generally respect their provider’s time, and most doctors report little, if any, impact from patients on their daily practice. Indeed, once underway, many report forgetting they were participating in a new intervention. But in recent surveys, about one in three doctors report taking somewhat more time to write notes, with fewer than 10% reporting taking much more time. We do not have independent verification of such reports. However, more than a few tell us that initially they took more time, but once settled in with this new transparency, they prepare their notes with the same efficiency as in the past.
Resources:
In numerous studies across multiple specialties, the majority of patients (93-99%) reported that reviewing their notes made them feel the same or better about their doctor, and more than half of the doctors participating reported that sharing notes led to improved patient satisfaction and trust.
Evidence is mounting: Sharing notes with patients can lead to better communication, more collaborative decision-making and stronger relationships. Perhaps most importantly, open notes can be powerful tools for enhancing patient engagement, and considerable research demonstrates that engaged patients have better outcomes.
Learn how open notes adds to the therapeutic appliance, builds stronger relationships and improves patient engagement.
Open notes can assist and support family, friends, and others who are care partners and caregivers. Forty percent of patients who read notes report sharing them with others, primarily family members. Shared notes help care partners manage the health needs of the people in their care, including scheduling visits, reconciling medication lists, and following through on a host of recommendations.
Importantly, transparent communication may be a powerful way to diminish stress and morbidity in the care partners themselves. In a recent study, care partners reported benefits from note sharing similar to those reported by patients. Additionally, care partner access to notes can serve as a bridge for patients with limited English, low health literacy, and those without computers or access to the Internet.
Enhancing mechanisms that offer ready proxy access to portals for care partners is clearly an important national work-in-progress. OpenNotes is engaged in research focusing on best practices and enhancing processes that meet the needs both of the individual patients and those caring for them.
During COVID
Care partners are often under enormous stress, and the Covid-19 pandemic has magnified virtually all the contributing factors. Transparent communication can play a large role in diminishing burdens care partners themselves experience.
View the Care partner toolkit to learn more.
Improved adherence to medications may be the most important clinical benefit transparent communication can confer. In a study published in 2019, a majority of patients reported that open notes improved their understanding of why and how to take their medications, and one out of six patients surveyed reported that open notes led them to adhere to their regimen more closely. Given that poor adherence to medications may cost the health care system as much as $300 billion dollars annually, this finding has striking implications.
In interviews and focus groups with patients and families, we have repeatedly heard anecdotes supporting these survey findings. Moreover, a study by the Geisinger Center for Health Research found that patients in practices offering access to notes were more likely to fill their prescriptions for blood pressure medication than were those in practices whose notes remained hidden.
Resources:
The digital divide persists. Individuals who do not usually speak English at home, have less than high school education, are nonwhite, older, or Hispanic are not as likely to register on patient portals and are therefore less likely to read their notes. However, in repeated studies, when these patients do get to read notes, they are those most likely to report benefits from note reading. Safety net institutions around the country, both hospitals and community-based health centers, have been joining the OpenNotes movement, and we receive many positive reports.
Resources:
Open Notes for Health Professionals
Navigating patient portals remains a challenge for patients. Patients often give up before finding what they need, and this includes finding notes. Health systems that make it easy for patients to access notes find that more patients choose to register for their portals and use open notes to full advantage.
Resources:
OpenNotes white paper: Implementing Open Notes: Improving patient access to notes on portals
OpenNotes Grand Rounds recording: Improving Portals for a Better Patient Experience
Most patients do not know that their notes are available for review. Indeed, more than a few don’t realize that clinicians write notes following visits.
Patients benefit from messaging about notes and your portal through multiple platforms, including posters, handouts, social media, email, text messaging, and person to person communication by members of the health team. A study of two health organizations, one with an electronic reminder system, and one that stopped reminding patients half way during a 2-year period, showed that patients viewed their notes far more often when accompanied by an email notification.
If you have an active Patient and Family Advisory Council (PFAC), we strongly recommend involving them in developing your communication materials about open notes.
Resources:
OpenNotes Communications Toolkit
OpenNotes Patient-Family Advisory Council Toolkit
OpenNotes Grand Rounds recording: Improving Portals for a Better Patient Experience
We’ve spent over 10 years studying the effects of open visit notes on patients, care partners and clinicians in a broad variety of ambulatory care settings. Time and again, studies show that open, transparent communication through visit notes are a good thing, across all demographics, and clinicians think open notes are a good idea.
Now, as a result of the Interoperability and Information Blocking Rule, all progress notes must be shared—including inpatient and emergency department notes. Since the focus of investigators has primarily been on office practice, we know little about the effects of sharing notes on inpatient services and in emergency rooms.
But there is developing experience. Learn with us: Tune-in to this Webinar case study about Open Inpatient Notes at UC San Diego Health on March 23.
Resource:
We study the effects of open visit notes on patients, clinicians, and care partners. We have not addressed test results released to patients through online portals. But there is considerable experience nationally with this issue. Using portals, some systems have invited patients to review such results for more than 20 years. These practices are quite variable. Some release everything the minute results are available. Others have selective embargoes…a CT scan or MRI may be published 48 hours later; pathology reports may be “blocked” for 2 weeks, and so on.
Now, with the Interoperability & Information Blocking Rule, we are hearing some consternation about the timing of the release of test results. Ideally, individual patients could specify their own processes. In our informal discussions with patients, some want immediate availability; others prefer to hear first from their clinicians, particularly if bad news could be on the horizon.
We know of little empirical evidence quantifying such divergent views. Our sense is that “embargoes” are in flux, and some EHR vendors are also enabling clinicians to make case by case decisions to block or delay results, hopefully with the individual patient’s needs and desires firmly in mind. This may become an example of where the “letter of the law” specifies one thing, and evolving “common law” heads in a somewhat different direction.
Ideally, patients should have a choice in the information they want to see, and when they want to see it. Overall, we are learning patients want to be in more control of their health information. This Information Blocking rule is an opportunity to invest in research and technologies that allow people to set their own information preferences. As portals and apps evolve in the future, offering patients more and more options will be part of a rapidly changing landscape of care.
Reading mental health notes can be a powerful tool in therapy.
Let’s show patients their mental health records JAMA (2014)
Sharing Psychotherapy Notes with Patients: Therapists’ Attitudes and Experiences Social Work (2020)
Sharing notes with mental health patients: balancing risks with respect The Lancet Psychiatry (2020)
Embracing the new age of transparency: mental health patients reading their psychotherapy notes online Journal of Mental Health (2019)
Patient access to electronic psychiatric records: A pilot study Health Policy & Technology (2017)
After you have a visit with your therapist or other behavioral or mental health provider, he or she summarizes information from the visit in a note that becomes part of your medical record.
In 1996, the federal Health Insurance Portability and Accountability Act (HIPAA) gave patients the legal right to receive and review the contents of their medical records, including therapy notes written by psychiatrists, psychologists, social workers, and others. However, HIPAA doesn’t guarantee easy access to one’s medical record. In fact, the process of requesting records can be tedious, time consuming, and sometimes expensive.
Therapists who join the OpenNotes movement are increasingly sharing visit notes with patients, either online using secure patient portals, or on paper. As this practice spreads to more and more health systems across the United States, many clinicians and patients are working to have mental health notes sit side by side with notes documenting the full range of visits to clinicians throughout the health care system.
In 2014, researchers and mental health professionals at Beth Israel Deaconess Medical Center (BIDMC) published an article outlining why they believe that open notes can be a valuable part of therapy for many patients managing mental/behavioral health and illness.
“By writing notes useful to both patients and ourselves and then inviting them to read what we write, we may help patients address their mental health issues more actively and reduce the stigma they experience.”
— Kahn, et al, JAMA, 2014
The content of mental health notes can vary depending on your clinician and the type of care you receive. Like medical notes, mental health notes often include a diagnosis, a summary of what you shared with your clinician, medication updates, your clinician’s assessment of your health, a treatment plan or next steps, and other information from your appointment. The notes may also include information required primarily to satisfy professional and health insurance requirements.
It’s okay to ask! If you’re interested in gaining access to your therapy notes, it’s a good idea to start by talking with your clinician. He or she may be able to print out your notes or support your request to read your notes online using the secure, patient portal. If it’s more convenient, or you feel more comfortable sending a request by email.
Become more involved and feel more in control of your health care. After a visit, you can read your notes to review what you discussed with your clinician, your treatment plan, any changes to your medications, and to remind you of any follow-up steps. In between visits, you can read your note to make sure you are following the treatment plan and to remind yourself to follow up on recommended procedures, tests or appointments. In preparation for your next visit, you can read your note to remind yourself what you discussed at your last appointment. You might also think about any steps you have taken, and any changes or new problems you may be experiencing since your last visit. The notes can also help you prepare a list of questions to review with your therapist at the appointment.
Feel empowered. If you have worries or concerns, it may be helpful to read through the first note or two together with your clinician so you know what to expect. It can take some time to get used to how mental health notes are written. But it can be empowering when you recognize your own capabilities in reading notes, discussing them with your therapist, and using them constructively in many different ways. We have learned that open notes can build trust in yourself and between you and your clinician. Reading your notes may even improve your self-awareness and self-confidence.
“I read my notes because it helps me see the progress I’ve made and the successes I’ve already had. Being in mental health care is hard work. It’s a lot of effort for me to come here and it can be draining at times. When I look back at my notes from last year, I get to view how far I’ve come.”
– Larry, Veteran
Organize care and track progress. Just as in any other appointment, there’s a lot to remember. Going back to read the notes after the appointment may help you manage your illness more effectively. Reading notes can help you understand your condition, your treatment, and your progress between visits. It can remind you of your responsibilities in your own care, including ‘homework’ or follow-up issues to work on between sessions.
Use your notes as a tool for change. You may find that discussing the information in your therapy notes with your clinician can decrease stress you might otherwise hold alone. In addition, you may find that the notes help you to benchmark your progress and motivate you to confront challenges and address difficult changes you hope to make.
“I have a tough time recognizing that I’ve made progress. So it’s nice to read this as a reminder.”
— patient, David , New York Times
Enhance trust and the therapeutic relationship. A trusting, therapeutic relationship between a patient and therapist is critical to progress and recovery. Being able to read what your therapist writes can help demystify what he or she is thinking. For many patients this can lead to a stronger relationship and richer conversations. It can also help you and your therapist initiate more open discussions about potentially difficult topics.
Help make your care safer. When you review your health record, including your medical history, current symptoms, medication dosages, and the care plan, you can help ensure that your record is accurate. When your medical record is up to date and accurate, your care is safer.
Make sure you’re on the same page. Sharing notes serves as a cross-check, improving the likelihood that you and your therapist have a mutual understanding of what was discussed. The notes may also include comments from your therapist about differences in each other’s perceptions and understanding. Understanding these differences can be an important part of any therapy.
“Confident in the communication between my therapist and myself, eager to tell more.”
– a patient
Share with a family member or other clinician. Interactions between you and your clinician, and the notes documenting those interactions, are confidential. However, whether they are entirely private is up to you. You can share your notes with anyone you choose. Indeed, you may find it extremely helpful to share your notes with family members, friends, or caregivers who assist in your health care. Sharing notes with trusted friends, family, or caregivers, or other clinicians involved in your care may help keep people up to date with any changes in your medications, health conditions, or care plan. It may also help caregivers or care partners to coordinate your care. But always remember that your personal health information is private, and only you should choose with whom to share it.
Everyone’s experience is different, and many people have questions or concerns. As you read your mental health notes, keep in mind that they vary in length, may include sensitive information, or could have unfamiliar terms or confusing language that’s often required for meeting professional standards. You should feel free to discuss with your therapist issues for you that notes reveal. You may also choose not to read them! Reading such notes may not feel right for whatever reason, and that’s okay too. You know yourself best. It’s important to respect that, and to talk with your therapist about your preferences.
Talking about the things that affect our lives, especially topics that can be difficult to discuss, can be important for recovery in mental health. Here are some strategies for getting started with using open notes as a tool in your therapy:
Talk with your therapist about your expectations with note sharing. This conversation can also help you learn more about your treatment and your clinician’s perspectives. Things you might want to discuss include:
If you’re nervous or worried, you may want to consider asking your clinician if you can read some of your notes together.
Develop a plan for what you should do if you become worried or upset by reading your notes, or if you disagree with something written in the notes. This may include talking with a trusted friend or family member, taking a walk, or relying on other strategies that work for you.
“The most important thing is to talk with your therapist about all the typical ways you manage your well-being between visits and how those same strategies can be used while reading your notes.”
— Steve O’Neill, LICSW, JD, OpenNotes Specialist, Social Work Manager for Psychiatry and Primary Care, BIDMC
The U.S. Department of Veterans Affairs (VA) was one of the first health systems to open all notes to all patients. The VA developed the R.E.A.D. Strategy to help patients get the most out of their mental health notes.
Questions are good. You can ask your therapist, “How are you going to write about this in my note?” But, it’s important to remember that while the patient has a right to access to the record, the health professional must still satisfy professional requirements and standards.
Sometimes notes are closed. If your therapist feels that reading the information in a note might be harmful to you, he or she may keep the note from being available on the patient portal. If a note is unavailable, talk with your therapist. Again, you might suggest reading the note together.
Open notes are not for everyone. For some patients, just knowing the notes are there and available is enough. Some use the notes as reminders of the work to do between visits, and, for a variety of reasons, others choose not to read their notes. Open notes is a good example of freedom of choice!
Boston hospital pilot gives patients electronic access to their therapists’ notes, Washington Post
What the therapist thinks about you, New York Times
Doctors’ notes on mental health shared with patients, Boston Globe
Would You Want to Read Your Therapist’s Notes?, Shape Magazine
Clinic lets patients read their therapist’s notes, BBC World Service
Should therapists give their patients access to mental health notes?, KPCC-FM 89.3 Southern California Public Radio
Beth Israel Opens Mental Health Notes To Some Patients, WBUR-FM 90.9 Boston’s NPR News Station
Learn how to cite OpenNotes in your work.
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