Cures act

[AcronymAllergy]

The statute you quoted reads as thus

" Psychotherapy notes means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual's medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date."

It is vague, but would appear to me to be clearly referring to process notes. I, and many others, consider therapy notes what goes into the chart, and process notes what is separate from those EMR notes.

I don't think it would be harmful except in rare circumstances for patients to have access to therapy notes. It would only harm the therapuetic alliance if you were intentionally keeping something from them. If some patients do not like being reduced to a diagnostic label, don't reduce them to one, Fact is, something needs to be billed and they often meet criteria for a disorder that must be documented. Easy, have that conversation with the patient. I used to do a lot of treatment with people with Borderline PD, you always have frank conversations about the diagnosis. By and large, not discussing these things is more about the clinician avoiding a hard conversation than any real desire to protect the patient.

As for malingering or resistant, specific issues. We in neuro do not use malingering unless it meets strict definitions. Otherwise, poor effort or poor motivation suffice, I've done that feedback literally hundreds of times, in a very frank way. If the data and context point you in that direction, it's what you do. I don't believe in lying to the patient. As for resistant, I've had some of my best treatment gains with patients after frankly discussing their resistance to aspects of treatment.

Bottom line, clinicians need to get over their own fears and anxieties, stop treating patients as extremely fragile, and be more open and honest with them. That's how you avoid damaging the therapeutic alliance, not by lying to them by omission.

Agreed with the above. My understanding is that it can be difficult to impossible to make the argument that all notes of a certain type are harmful to the patient. After all, patients have a right to be informed about their care, and (to a large extent) to know what their providers are writing about them and how treatment decisions are being arrived at in chart notes. I would say if you're including things like diagnostic information in notes that hasn't been discussed with patients, that could be problematic.

I can see not wanting a patient to have access to certain notes before you've had a chance to review it with them, which is one of the areas that the Cares Act is causing concern for some providers (e.g., patient seeing an imaging or pathology report mentioning cancer before it's been discussed with them; patient reading a neuropsych report before results have been explained). But it's a difficult case to make that all therapy notes could potentially be harmful to a patient. If nothing else, imagine how that could be perceived by a patient, and the impact that might have on rapport.

In my case, I encourage all patients to obtain copies of their reports for their records. Many of the psychologists and psychiatrists in my clinic do the same regarding treatment/chart notes.

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[WisNeuro]

I can see not wanting a patient to have access to certain notes before you've had a chance to review it with them, which is one of the areas that the Cares Act is causing concern for some providers (e.g., patient seeing an imaging or pathology report mentioning cancer before it's been discussed with them; patient reading a neuropsych report before results have been explained). But it's a difficult case to make that all therapy notes could potentially be harmful to a patient. If nothing else, imagine how that could be perceived by a patient, and the impact that might have on rapport.

Depends on your organization's rules, but I don't post the report until after the feedback. Unless the patient refuses a feedback session, though that has been exceedingly rare IME.

 

[AcronymAllergy]

Depends on your organization's rules, but I don't post the report until after the feedback. Unless the patient refuses a feedback session, though that has been exceedingly rare IME.

Yeah, that's definitely an option to prevent it from happening (and to prevent other providers from potentially mis-reporting the results to the patient). But like you've said, sometimes that can be impacted by organizational rules about deadlines on posting chart notes.

 

[AbnormalPsych]

that the access requested is reasonably likely to endanger the life or physical safety of the patient or another person. The written statement must specify the portion of the record being withheld, the reason for denial and the duration of the denial.

That is a pretty high bar....unless you are doing some really intense work.

 

[singasongofjoy]

Did you not discuss privacy vs confidentiality? Parents typically always have acces to their children's chart. I would suggest you discuss this with your patient because they never really had confidentiality in the first place

In my AMC parents cannot access parts of their child’s notes /med chart after a certain age. Or at least not going through a bunch of hoops. I’ve never known it to happen. And even before any records are released directly to the client even if it’s just note from the diagnostic interview write up, medical records contacts me to see if there is any reason to think directly releasing them might have adverse impact. I haven’t heard wind of any potential changes coming down the pipes. That being said I have worked in other settings where there were basically 2 sets of notes. General ones that went into electronic record and more detailed that stayed in clinic which would take much more to access

 

[parametric]

Looks like the deadline has been extended til April (though some institutions are still going ahead with the November date):

HHS extends deadline for patient access to your clinical notes

Government cites the COVID-19 pandemic as the reason for the delay.

www.mdedge.com

 

[foreverbull]

Interesting discussion. I was taught years ago that if a client or other provider/third party asks for your notes over a certain time period (not talking about diagnosis, treatment plans, or termination summaries), you compile/provide a written summary of the work for the dates they requested rather than provide the actual individual progress notes as is. I don’t recall when I was taught that by a supervisor, but is anyone else familiar with this approach to releasing info or is this not considered a valid way to release PHI?

 

[PsychPhDone]

Interesting discussion. I was taught years ago that if a client or other provider/third party asks for your notes over a certain time period (not talking about diagnosis, treatment plans, or termination summaries), you compile/provide a written summary of the work for the dates they requested rather than provide the actual individual progress notes as is. I don’t recall when I was taught that by a supervisor, but is anyone else familiar with this approach to releasing info or is this not considered a valid way to release PHI?

While studying for the state exam, I believe the materials said you could offer a summary but they could still request notes. It might vary by location.