psychotherapy note exception to release of info requests and the VA

[JeyRo]

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So apparently I just got word today that officially, I am no longer able to my restrict patients from viewing their psychotherapy notes in their chart, as is explicitly allowed under California Health and Safety Code section 123115(b).

This has come down from the VA Central Office via the Privacy Office, because they want patients to have access to their records, ultimately, via MyHealthEVet.

I should say, I have only once in my entire seven-year career as a practicing psychologist and therapist felt the need to restrict a patient's access to their notes for a mental health reason. However, in that one case it was utterly critical, in my view, that I did so, for fear of sparking an escalation of suicidal risk and/or risk of violence to others. It was a serious situation.

I have asked for some guidance as to how we're all supposed to manage these situations now, but as of yet no response. I know that there are many states, not just California (where I practice) where mental health professionals are afforded this mechanism to safeguard their patients' mental health and safety, under certain circumstances.

Opinions? You know mine. I'm bothered.

 

[PHD12]

I know that the VA was moving towards allowing veterans to access records online. Does this mean that they automatically have access to MH notes without even requesting them? I can see many situations where this would backfire, particularly when you are diagnosing patients, documenting factors such as avoidance/minimizing, discussing underlying personality issues that are interfering with treatment etc.

 

[JeyRo]

I know that the VA was moving towards allowing veterans to access records online. Does this mean that they automatically have access to MH notes without even requesting them? I can see many situations where this would backfire, particularly when you are diagnosing patients, documenting factors such as avoidance/minimizing, discussing underlying personality issues that are interfering with treatment etc.

It means in practice VA patients could potentially be sitting in their hospital rooms, accessing their documentation in real time as their nursing and interprofessional staff (including their psychologists) generate their notes.

I'm no paternalist, but what a nightmare.

 

[PHD12]

It means in practice VA patients could potentially be sitting in their hospital rooms, accessing their documentation in real time as their nursing and interprofessional staff (including their psychologists) generate their notes.

I'm no paternalist, but what a nightmare.

Complete nightmare. I can already imagine some VA patients I've worked with where this scenario would quickly escalate and potentially cause more harm than good.

 

[JeyRo]

Complete nightmare. I can already imagine some VA patients I've worked with where this scenario would quickly escalate and potentially cause more harm than good.

I just concluded an exceptionally bad situation at my hospital with a terrible, highly symptomatic Axis II patient (who we ended up sending to the psych. ER) and one of the issues that was so terrible about him was that he was regularly accessing his medical records while an inpatient and intimidating the nursing staff with what he found in there (e.g., threatening with administrative complaints, lawsuits, and threats suggestive of intending to physically harm staff at times, etc). Fortunately, I was able to use this psychotherapy notes exception to shield some of my notes from him, on the basis that discussions of discharge planning (which were in my notes) would cause him to escalate and decompensate and become potentially homicidal or suicidal.

 

[Pragma]

Couldn't there be some kind of designed delay in the system? I don't see how it works realtime (unless the VA system is very different) because people make addendums during hospitalizations all the time. Could it be available after a certain amount of time has passed to prevent patients from complaining about typos and what-not?

Also, not to be too disagreeable here, but I write all notes/reports as if the client is going to read them. I don't see any problem with routine access to medical records unless there is a clear risk of harm. Obviously that doesn't include things like raw data, my own personal notes, etc. What goes in the record is airtight (or should be, IMO).

 

[psychRA]

My understanding from our TD is that this will only apply to notes from January 2013 onward. I don't believe that it applies to existing notes that were written prior to that time. So yeah, it's still terrifying, but at least we're aware of it moving forward, and it doesn't affect notes from the past.

ETA: to second what Pragma has said, I tend to write my notes with the assumption that they will be read by a patient and/or an attorney down the road. Unlikely that it will come to that, but it can't hurt to be prepared.

 

[JeyRo]

My understanding from our TD is that this will only apply to notes from January 2013 onward. I don't believe that it applies to existing notes that were written prior to that time. So yeah, it's still terrifying, but at least we're aware of it moving forward, and it doesn't affect notes from the past.

ETA: to second what Pragma has said, I tend to write my notes with the assumption that they will be read by a patient and/or an attorney down the road. Unlikely that it will come to that, but it can't hurt to be prepared.

I should emphasize - I have only once used this with my psychotherapy notes, only once, in my entire 7 year career thus far. I consider all my notes (more or less) designed to be "airtight" and objective. But that still doesn't mean that sometimes there's a really unbalanced patient who will potentially go ballistic reading your notes (e.g., due to psychosis, Axis II issues, etc).