LAUSR

As of April 5, 2021, as part of the final roll out of the 2016 21st Century Cures Act, all healthcare providers are required under federal law to provide patients with immediate access to their health data upon their request, including mental health providers’ clinical notes (psychotherapy notes continue to be exempt). Referred to as Open Notes, this initiative to promote transparency by sharing healthcare documentation was started over 10 years ago at Beth Israel Deaconess Medical Center. Studies performed over the last decade have shown the benefits of open notes including improved patient satisfaction and safety as access to their medical record has helped patients understand their medications and feel more in control and comfortable with the treatment plan [1]. Open notes may even play a role in improving healthcare equity as one study showed less educated, non-white patients of Black and Hispanic origin, especially those who do not speak English in the home, reported major benefit to reading clinical notes [2]. Mental health clinics have lagged behind in transparency due to the concern that disclosing sensitive topics, such as substance use, trauma, and stigmatizing psychiatric symptoms in notes may be more harmful than helpful to patients [3]. Nevertheless, positive effects have been noted in settings with open notes including empowering patients to actively address mental health and illness, reduced stigma associated with mental illness and its treatment, and enhanced therapeutic alliance [4]. With the final implementation of the 21st Century Cures Act, Open Notes is now in mental health settings, and psychiatry residents are in need of guidance and supervision on how to adapt existing documentation habits to meet the demands of progressive medical record transparency. In a survey of 176 residents working in primary care clinics about the impact of open notes on education and patient care, most residents agreed open notes would have a positive impact on patients. However, 62% reported they received limited faculty feedback on their clinical notes, and 54% were interested in educational initiative to help them write more useful notes [5]. Residents already devote an enormous amount of time to documentation, and the prospect of patients reading their notes is an additional layer of complexity [6]. The aim of this article is to provide tips and techniques based on experience and informed by available research about open notes. We aim to teach psychiatry residents how to confidently write notes that are a clinically meaningful part of the medical record and simultaneously sensitive to the mentalhealth-patient-audience. We will break down specific skills useful in outpatient clinic practices and inpatient hospital settings.