Open Notes for Mental Health Clinicians

Overall, open notes improves the therapeutic experience for most patients. As clinicians implement open notes throughout a broad range of specialties, their concerns remain consistent for mental health or illness. They worry that sharing notes with patients will require changing the way they work. They fear that patients will become anxious, confused, or angry after reading notes. These concerns are often heightened in particularly sensitive areas of care, including oncology, obstetrics, emergency medicine, pain management, and especially in mental health.

“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

In 2014, about 40 psychiatrists, psychologists, and social workers at Beth Israel Deaconess Medical Center (BIDMC) in Boston began sharing notes with close to 1,000 of their patients. The response to this intervention was similar to reactions to open notes in other areas of care. For the most part, health care professionals’ fears were not realized. They reported little change to workflow, and the patient response was overwhelmingly positive.

In the years since that study, the results have been replicated in a number of studies, including a large study focusing on persons with severe mental illness. It showed that two-thirds of nearly 30,000 patients felt that reading notes helped them to better understand why their medications were prescribed, feel more comfortable in taking their medications, and answer their questions.

“We can certainly say at this point, the angst which most clinicians feared by sharing their notes is not materializing. It has been strikingly quiet in this regard, with scattered exceptions. The vast majority of our patients are reporting that the notes are helpful and often clarifying.”
—Steve O’Neill, LICSW, JD, Social Work Manager for Psychiatry and Primary Care, Beth Israel Deaconess Medical Center

The benefits and harms of open notes in mental health: A Delphi survey of international experts, PLoS One (2021)

Association of patients reading clinical notes with perception of medication adherence among persons with serious mental illness | JAMA Netw Open (2021)

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For most patients, yes! Not all patients choose to read their therapy notes, but most do when offered access. For some patients, open notes serve as a tool to extend the therapy between sessions. Patients and health care professionals alike have reported benefits, including:

Demonstrating respect and reducing stigma. Open notes can help bridge the gap between physical and mental health care. Patients should be managed similarly, whether receiving support for a mental or a physical ailment. To treat the two differently may unwittingly reinforce stigma most therapists try to diminish, adding to barriers that often prevent patients from seeking treatment in the first place.

Empowering patients. The act of inviting patients to read what their clinicians write suggests that patients are competent and capable of understanding and discussing their own health. This open, respectful approach can mitigate power imbalances in clinician-patient relationships. Additionally, using the note to reinforce patients’ positive traits and to place their circumstances in a broader context can improve patients’ self-awareness and self-confidence. As is true on the medical side, patients repeatedly tell us that they look for concordance between what is said in the office and what is written in the note.

Organizing care and tracking progress. Open therapy notes provide a therapeutic opportunity to help patients manage their illness more effectively. Reading notes can help patients understand their treatment and progress (or lack thereof). It can reinforce the responsibilities of their care, including “homework” or follow-up issues to be worked on between sessions. Moreover, transparency in therapists’ notes can serve as a type of modeling that, in turn, encourages patients to be more open and transparent.

“I have a tough time recognizing that I’ve made progress. So, it’s nice to read this as a reminder.”
—David, patient, New York Times

Providing a tool for behavior change. Patients may find that a balanced discussion facilitated by open therapy notes helps with anxieties they otherwise hold alone. In our research, clinicians found that when some patients read medical notes about sensitive subjects, including substance use disorders, they were more motivated to confront these challenges.

Enhancing trust and the therapeutic relationship. Trusting therapeutic relationships are critically important for progress and recovery. Note sharing can demystify what the clinician writes (and thinks), helping patients to feel treated as complete individuals, rather than as a collection of symptoms. Open notes may promote richer dialogue between the patient and clinician. In turn, the therapist may initiate more frank discussions about potentially difficult topics, including the patient’s diagnosis.

Making care safer. Allowing patients to review what was said about their symptoms, medication doses, etc., helps ensure that the record is accurate. Sharing notes also serves as a cross-check, improving the likelihood that the patient and clinician are on the same page. Open notes promote partnership and cooperation among all parties to promote the safety of care.

“Sometimes when I am in session with [him], I wonder, Does he understand what I am trying to get across? I get to see if he does.”
—A patient

Potential for reducing workload. Open notes can extend the work of the session between visits. As with all medical visits, many patients have a hard time remembering what was discussed in sessions. Note sharing may help patients find information without requiring additional communication with their clinician. The availability of notes may result in fewer messages and phone calls between appointments, as well as more efficient note writing as clinicians shift to “plain language” when appropriate.

Sharing clinical notes in psychotherapy: A new tool to strengthen patient autonomy | Front Psychiatry (2020)

Association of patients reading clinical notes with perception of medication adherence among persons with serious mental illness | JAMA Netw Open (2021)

Read more research

Perhaps! Clinicians often worry about how to document sensitive issues, including substance use disorders, trauma, and a variety of psychiatric diagnoses. Inviting patients to read these notes presents new challenges.

Here are some things to consider when writing open therapy notes:

The invitation is important. The simple act of inviting patients to read their notes helps establish a safe environment for discussion, whether they choose to engage with the notes or not. And patients who do read notes are often relieved to see what their therapist is writing. This type of transparency can lead to mutual trust and enhance the therapeutic relationship.

Promote transparency. It’s natural to want to avoid some challenging conversations with patients, but transparency may encourage more open and active communication. Unless you believe a conversation might harm your patient, a good rule of thumb is to write about things you discussed and to discuss with your patients content you will write about.

Avoid or define medical jargon. Spell out acronyms and abbreviations. We’ve learned that patients don’t expect clinicians to change the way they write notes. Still, small changes can help make the note more useful for patients between sessions. And many patients have told us that they greatly appreciate seeing something they said quoted in open notes. They feel listened to, even when there are differing perspectives.

Use plain language. Open notes can reinforce trust when the notes are transparent and respectful, but they can diminish trust when notes are disrespectful or don’t accurately represent a session. Using ”plain language” helps. As an example, some patients have expressed concerns that the term ”affect dysregulation” might be a judgmental term. In this case, it’s an easy switch to simply use the word ”upset.“ Still, it’s important to explain to patients that there are professional standards and health insurance requirements that need to be satisfied. Explaining and setting expectations is key. It is also a requirement for proper informed consent.

“When we think about our patients in a kind of language that we deem inappropriate or potentially offensive to the uninitiated, who is to say that our own attitudes toward our patients are not affected by that language? Wouldn’t we be closer to our patients’ experience if we got into the habit of thinking about them in language they would find meaningful and useful?”
—Kahn, et al. Let’s Show Patients Their Mental Health Records. JAMA, 2014

Engage patients in the documentation. Let your patients know it’s okay to ask, “How are you going to document this?” This doesn’t mean the patient decides what can or cannot be written. While the patient has a right to access to the record, the clinician must still satisfy professional requirements and standards. It may be helpful to communicate about documenting particularly sensitive issues.

Develop options if a patient’s access to notes may carry more risk than benefit. You may decide with the patient to keep the notes closed, or to monitor or sequester certain notes. You might discuss embargoing a note until a future date, or suggest reading the note together. Therapists may want to revisit these options at any point during treatment. For example, patients dealing with trauma may find reading a note about their trauma triggering. Talking with your patient about when best to read such a note also may be helpful.

Protect against abuse. Health care professionals worry about certain patients opening notes if those notes may run the risk of being more harmful than helpful. You should work closely with your patients to ensure safety. Patients who are victims of domestic violence, or are at risk for abuse, are especially vulnerable and warrant special consideration. For these patients, the same precautions are true for all other aspects of the medical record and should be applied to therapy notes. And many of these patients may well fall under a “blocking exception” if accessing the note might increase the danger of harm.

Discuss the diagnosis. We recommend that diagnoses and other important details be discussed with patients before documenting. This way, patients aren’t learning something for the first time in the note. This can be especially true, and challenging, when documenting a differential diagnosis or condition, just as is the case with illness affecting the kidneys or lungs.

Create a plan. We suggest having a discussion with your patients and together deciding on a plan for worried or upset feelings related to their notes. They may also disagree with something in their note. Setting realistic expectations is highly important, just as it is with any other aspect of a patient-clinician relationship.

Let’s show patients their mental health records | JAMA (2014)

Impacts of a web-based course on mental health clinicians’ attitudes and communication behaviors related to use of OpenNotes | Psychiatric Services (2019)

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Here are some examples of how to write mental health notes that are clinically meaningful and educational for you, your patient, and your patient’s care team. Written by a psychiatrist at Beth Israel Deaconess Medical Center, in Boston, these examples are based on scenarios encountered by health care professionals.

A patient experiencing delusion

Scenario: Mr. A is a man with schizophrenia who believes that the FBI has placed “invisible” microphones and cameras in his apartment. He takes 1 mg of risperidone daily “to keep my family off my back,” but you are trying to get him to take a higher dose. You have tried to discuss his diagnosis with him, but he dismisses it, and believes that “schizophrenia was made up by the FBI to incarcerate subversives.”

Sample note: Mr. A says he is taking 1 mg risperidone daily, but he continues to be convinced that the FBI is monitoring him. We disagree on this, as we do about whether he has a psychiatric problem in the first place. I believe that a higher dose of risperidone would help him with the anxiety he feels about being monitored, but he firmly refused to increase the dose to 2 mg daily. I nevertheless urged him to consider a brief trial of the higher dose, to see if he noticed any benefit. We will continue to assess his overall level of anxiety and how it affects his daily functioning. I am concerned that his anxiety limits his ability to feel safe on a day-to-day basis. But on a happier note, he continues to be very interested in current events and reads newspapers and books extensively.

A patient with borderline personality disorder

Scenario: Ms. B is a young woman who frequently self-mutilates to manage stress. She is taking fluoxetine and aripiprazole for anxiety and depression. They help increase her stress tolerance to a certain extent, but she finds that ongoing use of alcohol and marijuana “help me more” with anxiety. Her relationship with her boyfriend continues to be marked by frequent verbal fights and occasional pushing. You are trying to explore other medication options and also to encourage her to try dialectical behavior therapy.

Sample note: Ms. B’s condition remains about the same as it was during our last visit. She feels the medication helps somewhat, but I have shared my concerns with her that her continued use of marijuana and alcohol likely interferes with the ability of the medication to help. She recognizes her frustration and unhappiness, however, and was open to discussing a referral for dialectical behavior therapy. I think this could be very helpful for her. I also raised the question of AA. We agreed to see how she felt after a week of going without alcohol and, if she can do this, we will consider a low dose of lithium to help her with her moods. While she has her ups and downs at her job as a receptionist, she does feel her boss is supportive, and that’s encouraging.

A patient with a history of sexual trauma

Scenario: Ms. C is a woman in her thirties whom you have seen for a year for depression and who now reveals that she was molested by an uncle several times when she was nine. She has never revealed this to anyone before and was overwhelmed with feelings when she mentioned it. She asks you not to reveal this in the medical record.

Sample note: Ms. C is functioning well on citalopram 40 mg qd, sleeping and eating well, and doing well at work. Today she mentioned some incidents in her past that we have not discussed before and that were very significant for her. We will continue the citalopram and explore the incidents when we meet next.

A patient who is being less than honest

Scenario: Mr. D. is a man in his twenties whom you have been treating for anxiety. You get a call from a pharmacy saying he has been filling prescriptions for a benzodiazepine from a physician you have never heard of. You tactfully confront Mr. D with this information, and he gets very upset and leaves the visit prematurely, saying he can’t trust you anymore.

Sample note: Mr. D. said he has been doing well on fluoxetine 20 mg qd and clonazepam 1 mg bid for anxiety, and that he enjoys his new job as a mechanic. I told him I had been contacted by a pharmacy to ask me if I knew he was getting alprazolam from a different doctor, and I asked him if we could discuss the issue. Unfortunately, he became very upset and told me that the alprazolam was “none of your business.” I told him I thought perhaps his anxiety was under treated on the regimen I have been giving him, but he did not want to discuss it and left the office suddenly. He did not make a follow-up appointment, and I will send a letter inviting him to do so.