Keeping good documentation and keeping up with all of the guidelines from licensing boards, ethics codes, and agencies can be challenging. Add insurance companies to the mix, and it often feels overwhelming to make sure your notes meet everyone's requirements.
Client notes help you keep a record of what worked and what did not or the chance to see patterns of symptoms of behaviors. Your notes also give your clients continuity of care in the event they switch providers or return for more sessions and treatments.
Recently, you may have seen information about yet another requirement for your documentation with the introduction of the 21st Century Cures Act. The Cures Act puts in place new rules about sharing notes with clients. Let’s take a look at how this may affect you.
The Cures Act prohibits a practice called "information blocking," or activities that interfere with a patient's access to electronic health information. This regulation is designed to give patients direct access to clinical notes from their providers, a concept promoted by the OpenNotes movement. It is intended to help facilitate information sharing and encourage transparency in the clinical process. While certainly noble and helpful in many cases, the idea of clients having direct access to their notes may give many therapists some concern.
There's good news: it is highly likely that this regulation does not apply to therapists in private practice. According to OpenNotes.org, psychotherapy notes that are kept separate from the rest of an individual’s medical record (i.e. primary care provider) and are 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 are excluded.
This regulation is part of the ONC Certified Electronic Health Records Technology (CEHRT) program. The CEHRT program is a set of standards established by the federal government to ensure that EHRs can perform certain functions and work together to share information. However, these standards often apply best to other medical professionals and environments, such as primary care doctors and hospitals. You may remember the concept of “meaningful use” and how psychologists and other therapists were specifically excluded from participation. Therapy does not involve ordering imaging tests or bloodwork or quantifying observations like blood pressure and heart rate. The qualitative nature of therapy documentation does not fit well with the model used for sharing health data, and additional privacy concerns often keep therapy information out of this process.
Since these standards do not apply well for therapists, and in many cases therapists are unable to participate in any benefit programs that require CEHRT technology, TherapyMate has not chosen to participate in the voluntary certification program. Since TherapyMate is not part of the CEHRT program, the regulation does not apply, and your clients will not have direct access to their progress notes through the client portal system. When your client does request access to their notes, TherapyMate makes it easy for each clinician or practice to download a copy of your client’s notes and you can share these notes securely with your clients via TherapyMate’s client portal. In cases where the information is highly sensitive, you can store the information in process notes which are typically considered separate from the rest of the record and are generally not released.
Please Note: The content of this article is intended to serve as general advice and information. It is not to be taken as legal advice and may not account for all rules and regulations in every jurisdiction. For legal advice, please contact an attorney.