Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make healthy choices.1 Mental health is important at every stage of life, from childhood and adolescence through adulthood.
Mental and physical health are equally important components of overall health. For example, depression increases the risk for many types of physical health problems, particularly long-lasting conditions like diabetes, heart disease, and stroke. Similarly, the presence of chronic conditions can increase the risk for mental illness.2
Mental Health Notes Pdf Download
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Objective: This study describes responses to OpenNotes, clinical notes available online, among patients receiving mental health care and explores whether responses vary by patient demographic or clinical characteristics.
Methods: Survey data from 178 veterans receiving mental health treatment at a large Veterans Affairs medical center included patient-reported health self-efficacy, health knowledge, alliance with clinicians, and negative emotional responses after reading OpenNotes. Health care data were extracted from the patient care database.
Most of us did not go into the mental health field because we love administrative tasks, and yet we find ourselves spending a tremendous amount of our professional lives completing progress notes and other forms of documentation.
The exact content of a progress note will vary depending on state, local, and organizational requirements. Yet, most mental health providers, including psychologists, social workers, marriage and family therapists, and others, write progress notes after each visit that describe:
Interventions: Practiced visualization and grounding techniques to untangle different emotions and learn how to self regulate. Completed the PCL-5 as a rating scale to track progress and as a clinical tool to implement grounding techniques in moments of heightened distress. Scored a 45.
Originally developed for use in healthcare, the SOAP method is another common template for progress notes that some therapists and mental health providers use. SOAP is an acronym that includes four parts:
Objective: Scored a 45 on the PCL-5. Affect was appropriate if slightly constricted. Speech was coherent and normally paced and thought content was clear. Thought process presented as fragmented, tangential, and filled with loose associations congruent with her PTSD diagnosis. Denied SI/HI.
Background: As part of the national OpenNotes initiative, the Veterans Health Administration (VHA) provides veterans online access to their clinical progress notes, raising concern in mental health settings.
Objective: The aim of this study was to examine the perspectives and experiences of mental health clinicians with OpenNotes to better understand how OpenNotes may be affecting mental health care.
Methods: We conducted individual semi-structured interviews with 28 VHA mental health clinicians and nurses. Transcripts were analyzed using a thematic analysis approach, which allows for both inductive and deductive themes to be explored using an iterative, constant comparative coding process.
Results: OpenNotes is changing VHA mental health care in ways that mental health clinicians perceive as both challenging and beneficial. At the heart of these changes is a shifting power distribution within the patient-clinician relationship. Some clinicians view OpenNotes as an opportunity to better partner with patients, whereas others feel that it has the potential to undo the therapeutic relationship. Many clinicians are uncomfortable with OpenNotes, but acknowledge that this discomfort could both improve and diminish care and documentation practices. Specifically, we found that (1) OpenNotes is empowering patients, (2) OpenNotes is affecting how clinicians build and maintain the therapeutic relationship, and (3) mental health clinicians are adjusting their practices to protect patients and themselves from adverse consequences of OpenNotes.
Conclusions: Our findings suggest that future research should monitor whether OpenNotes notes facilitates stronger patient-clinician relationships, enhancing patient-centered mental health care, or diminishes the quality of mental health care through disruptions in the therapeutic relationship and reduced documentation.
The wording of the initial rule was confusing and seemed to state that therapy notes were an exception and did not need to be shared. However, a clarification was issued stating that the exclusion only applied to side notes or process recordings. All therapy notes should be shared with patients unless they meet the requirements for an exemption. For more information on exemptions, see our FAQ about the Cures Act federal rule.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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. 152ee80cbc
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