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September 2017

Open Notes, Progress Notes, race relations


In many previous editions of  Tips &  Topics I’ve written on treatment planning in the hopes of focusing less on paperwork and more on “people-work”.  How can we meet standards and get the documentation done to meet medical necessity payment requirements?  Obtain quality audits and accreditation, and yet have the paperwork be meaningful to help people – meaningful to both the client and the counselor and clinician?

So when I noticed an article by John Torous, M.D. and Pamela Peck, Psy.D. in  Psychiatric News it caught my eye.
Your clinical and progress notes can be much more than paperwork documentation.
The article was titled: “ Sharing Clinical Notes With Patients Improves Treatment Effectiveness”
and was published online: September 12, 2017  Psychiatric News – Sharing Clinical Notes

Here are some excepts from the article:
“The American Journal of Psychiatry published a paper in May 1980 titled “Patient Access to Records: Tonic or Toxin,” which discussed the controversial  topic of sharing psychiatry clinical notes with patients. An international movement known as OpenNotes has gained considerable momentum in the last several years and reignited interest within psychiatry.”
“OpenNotes allows patients to independently read their clinicians’ visit notes. Research on the impact of OpenNotes in primary care settings suggests”:

  • Improved communication between patients and clinicians
  • Greater patient engagement and adherence with care plans
  • Improvement in the quality of care.
The authors go on to to say that “the impact of sharing notes around psychiatric care had not been looked at specifically in a psychiatric outpatient setting.” They are coauthors of a study published in the September ScienceDirect. It “offers pilot evidence, as well as clinician and patients’ perspectives, on implementing OpenNotes in a busy outpatient psychiatry clinic.”
The Study

  • 15 mental health clinicians, including psychiatrists, a nurse practitioner, and social workers participated in the study.
  • They offered 568 of their patients immediate access to clinical notes through the hospital online patient portal over a 20-month period.
  • 30%, or 117, of the study patients read their notes.
  • 52 patients completed an exit survey about their experience with OpenNotes.
Survey Results

1. Patients found access to their visit notes helped them:

  • Better remember their care plans
  • Adhere to their medication regimens
  • Make the most of clinical appointments.
2. Clinicians reported that:

  • OpenNotes did not significantly increase their workload.
  • OpenNotes did not lead to complications in the treatment relationship.
  • These positive results may have been a function of patient selection for the study, which excluded many with psychotic illnesses and severe personality disorders.
3. The authors’ discussion:

  • “While it is a mistake to over-interpret the results of this pilot study, the results do suggest that offering select patients easy access to psychiatry notes is not “toxic.”
  • May improve treatment in an outpatient setting in an academic medical center.
  • It is hoped that the results will spur more interest and research in OpenNotes for psychiatry.”
More information about OpenNotes:  Open Notes
John Torous, M.D., is co-director of the Digital Psychiatry Program at Harvard-affiliated Beth Israel Deaconess Medical Center in Boston and a member of the American Psychiatric Association’s Committee on Mental Health Information Technology. Pamela Peck, Psy.D., is clinical director in the Department of Psychiatry at Beth Israel Deaconess Medical Center.
In collaborative, person-centered services and documentation:

  • Who should know their treatment plan best?
  • Who should know clearly what they are working on, to get what they want out of treatment?
  • Who should have input and a significant say in what goes into their Progress Notes?


If you go to the  Tips &  Topics Archives at, you can see previous editions on aspects of treatment planning:

July 2015  See July 2015
February 2015  See February 2015
July-August 2005  See July-August 2005
February 2005  See February 2005
June 2003  See June 2003
Choose five of your client charts at random, gather the treatment team and play “Name that Client” by reading the treatment plan one problem/priority at a time.
If the treatment plan is individualized based on an assessment of the participant’s specific needs, then after reading a few of the problem statements in the treatment plan, you should know which person we are talking about. So let’s try it:
Name that client: Problem #1 “In denial”
Name that client: Problem #2 “Low self esteem”
Name that client: Problem #3 “Lacks positive support system”
Name that client: Problem #4 “Legal problems”
Name that client: Problem #5 “Depression”
Name that client: Problem #6 “Poor impulse control”
You could read 10 problems and it could apply to so many clients. This shows this is a generic problem list more for documentation, than a person-centered care
See if this is better:
Name that client: Problem #1 “I was just in the wrong place at the wrong time to get that second DUI. I don’t have a drinking problem”
Name that client: Problem #2 “I don’t think anyone would want to sponsor me so I’m afraid to ask.”
Name that client: Problem #3 “All my friends drink or drug, but I don’t see anything wrong with that.”
Name that client: Problem #4 “I want to get off probation.”
Name that client: Problem #5 “I feel like crying all the time, can’t sleep properly and even feel suicidal sometimes.”
Name that client: Problem #6 “When someone ticks me off like that, they deserve a beating.”
When you look at the problem statement, ask yourself  What made me say that?”  If you can answer with something more specific which makes sense to the client, then document that answer, not something abstracted back one or two levels.
So for Problem #1 above, “ What made me say “In denial”? Well the client said “I was just in the wrong place at the wrong time to get that second DUI. I don’t have a drinking problem” Then that more specific “problem statement” is what to document.
For more suggestions on Problems, Goals and Strategies:
March 2006    See March 2006
March 2005  See March 2005
If all of the Progress Notes sound generic, check if you are really providing individualized, outcomes-driven treatment.
There is a problem if you read a progress note and it says something like:
Client attended group, gave positive feedback to others; is gaining insight and more in touch with her feelings. Continue current treatment objectives.”
Such a Progress Note:

  • Is just noting that the person attended group.
  • While it sounds like it is documenting progress, it is not clear what insights are being gained, what feelings are better understood, and what specific treatment strategies are to be continued.
  • It meets the letter of the law in doing a Progress Note, but doesn’t note what progress is being made on what issue.
How does this sound for a more meaningful Progress Note?
“Joe told Jane that she was quite confident in the role-play when she practiced asking for a sponsor. Seeing her do it helped him feel less intimidated about getting a sponsor for himself. Will try asking someone at the next AA meeting and report back to the next group session.
Actually, Joe could have written his own progress note if he was fully empowered in his treatment planning and ongoing progress.
For more suggestions on Progress Notes:
February 2006  See February 2006


I just returned from a conference in Roanoke, Virginia. The other trainers were having lunch at the same table and I was curious about a workshop being held at the same time as mine. The  topicwas race relations, co-led by a white man and a black woman. (I wished I had the opportunity to attend, however my workshop participants would have been quite upset if I had actually done what I joked: “You go ahead and read the handout while I attend the other workshop.”)
There was lots of interesting discussion but I asked the black woman trainer what was the best term to use: “African American” or “black”? I knew enough that the “n” word was totally unacceptable. I learnt some points I had not thought of before:
  • She said that for her, both terms were acceptable, but she preferred “black” because it has positive connotations linked to the civil rights movement of black power, Martin Luther King, and the fight for equality.
  • “African American” was more familiar and perhaps acceptable to younger people more removed from the history of the civil rights movement.
  • “Colored” was definitely a dated word with strong negative emotions and connotations harking back to the time when there were separate drinking fountains, toilets, seating on the bus etc.
  • Some black Americans object to “African American” because “I’m from the USA, not Africa.”
Other pearls I picked up were that “millennials” * are a delight to have in a workshop, as they are so much more willing to talk open-mindedly about race relations and tackle the tough questions. Older white participants often don’t know what they don’t know for example, disputing that there is any such thing as “white privilege”. Being white in a historically predominantly white society easily blinds you to the automatic privileges of being white.
(* “Millennials (also known as Generation Y) are the demographic cohort following Generation X. There are no precise dates for when this cohort starts or ends; demographers and researchers typically use the early 1980s as starting birth years and the mid-1990s to early 2000s as ending birth years.”
Like religion and politics, race relations is one of those  topics which stirs a lot of feelings and discussion, best avoided in polite gatherings. However, we live in an era, globally and in the USA, where a tweet, a political rally, a slew of policies on immigration and citizenship are so intertwined with race, religion and politics. One would have to avoid all news media and stop thinking to find conversations that don’t eventually turn to these politely avoided  topics.
It is inevitable we all harbor certain prejudices, biases and dark thoughts and attitudes about race relations. Maybe you believe you are evolved and enlightened enough that this is not true in your case.
I know I became a little more enlightened this week over lunch.
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