Are We Becoming Outdated?

In the not too distant past, a therapist with some kind of note pad in hand was the norm. It was expected. We were doing our jobs and interested enough in the client to take notes on what they were saying. I was part of that crowd. Although I preferred to write my notes after the client left, I definitely felt that paper notes were the way to go and I burned through many legal pads in the early years of my career.

When we started hearing rumors about healthcare practitioners being mandated to switch to digital record keeping and EHRs, many of my colleagues, myself included, were secretly or not-so-secretly glad that mental health practitioners had not been included in the mandate. We had been running our businesses the same way for many years and felt it was the way to go. Some therapists were even quite critical of the whole digital/EHR movement, feeling that the use of electronic records dehumanized the therapist/client relationship, which we all knew was so critical to our work. Others feared that electronic records weren’t safe, i.e., that they wouldn’t be able to adequately protect their clients’ privacy if they digitized their practice.

However, whether we like it or not, times seem to be changing. Two recent anecdotes have driven that home to me.

The first was a casual comment made by a friend. For some reason, the conversation had drifted to talking about therapists and their note-keeping practices. She was quite surprised when I told her that many therapists still took notes by hand. Without knowing my thoughts or biases, she stated that she was so used to her physical health practitioners taking notes on their computers or tablets, that if she were to go to a mental health professional and discovered they were taking notes by hand, she would see them as a bit antiquated. Furthermore, she took a perhaps unfounded leap and also said that it would make her question that therapist’s treatment methods. Since their business practices seemed to be antiquated, she questioned whether they might also not be up to date on the latest treatment techniques and innovations.

The second incident was even more surprising. In an initial interview, a potential new client revealed to me that she had interviewed another therapist, but that she learned that that therapist didn’t have a client portal. The client really enjoyed being able to interact with her other doctors via their portals and wanted to be able to do the same with her therapist so she decided to keep looking. This stunned me. It was the first time I had heard of a client actually rejecting a therapist solely because that therapist didn’t have a portal. And if you’re wondering, this was a woman in her 50s, maybe early 60s – not someone who had grown up in the digital age.

The implications here are clear. Although our profession was NOT among those mandated to use EHRs, the rest of the healthcare profession, whether they liked it or not, was forced to digitize. In the beginning, there was a lot of kicking and screaming among those professionals who were under mandate. Meanwhile, we mental health professionals were able to somewhat smugly keep doing things the way we had always done them. However, it seems that the tide is steadily turning and now our profession may be the one coming up short. Regardless of what healthcare professionals think of digital practices, consumers seem to be beginning to accept them as the norm. Those of us who don’t keep up, may be unknowingly turning away some of the very clients we’re hoping to attract.

Displaying Notes

Each client’s chart has a Notes tab on the top right:

Notes tab

Clicking “Notes” takes you to a page that serves as a repository for all notes that have been written about that client anywhere in PSYBooks:

Notes tab

The section at the top left of screenshot above is the Show Notes area:

Notes tab

Show Notes consists of filters to allow you to choose subsets of notes to view. Once you’ve chosen the filters you want, you can also create a PDF of that particular note subset.

The section on the top right is Add Notes:

Notes tab

Add Notes holds links to a few specialized notes you may want to use in PSYBooks including an open-ended psychotherapy note that is not part of the Medical Record.

Beneath Show Notes and Add Notes is the content area of the Notes tab which displays all notes and has a variety of tools for working with them.

Add Notes in PSYBooks

PSYBooks has fields where you can add notes to almost any form in a client’s chart. For example the area on the Add Session form for adding notes looks like this:

Notes on the Add Session form

This particular note area has optional formatting tools if you want to use them. There are radio buttons beneath the textarea that allow you to specify whether you want this note to be part of the medical record or a personal psychotherapy note, and a checkbox to the left of the words Electronic Signature which allows you to sign the note when you’re ready.

The checkbox that’s after the signature line and has an exclamation point beside it (Mark Important) is called the “Mark Important” tool. Checking this box will allow you to filter all notes that you have marked as important so you can view only those notes when you go to the Notes tab of the client’s chart. All notes in PSYBooks have both the signature line and the ability to mark a note as important.

The particular note above (i.e., the one on the Add Session form) also has an “Other Note Types” box in the upper right. This box has links to some structured notes you may want to use when you are adding a session: Intake Note, Treatment Plan and Progress Note. Structured notes have fields such as dropdown boxes and checkboxes which can allow you to fill out required data more quickly.

Your Personal Psychotherapy Notes (Hint: These Are NOT Part of the Client’s Medical Record)

PSYBooks does not store Psychotherapy Notes in the same way it stores notes that are part of the client’s medical record. Psychotherapy notes are meant to be places for you to record your personal thoughts or ideas about a client so they are stored separately. There is one note type in PSYBooks that is always in the Psychotherapy note category and four others that you can designate as Psychotherapy or Medical Record notes:

Can be in Medical Record > Clinical or Psychotherapy categories (you choose):

  • Add/Edit Client
  • Add/Edit Session
  • Add/Edit Client Family
  • Add/Edit Client Medication

Always in the Psychotherapy category

  • Add/Edit Open-Ended

Medical Record Notes

Almost all forms in PSYBooks have a section where you can enter notes. Most of these notes automatically become part of the client’s medical record, although a few allow you to designate the note as a personal psychotherapy note (i.e., not part of the medical record). PSYBooks breaks medical record notes into two categories: clinical medical record notes and admin medical record notes. This is done to allow you to give permission for a User to see one type of note but not others. For example, you might want your front office staff to be able to see your admin medical record notes (e.g., a note you might have attached to a client payment), but not your clinical medical record notes or your personal psychotherapy notes.

Most of the note types are assigned by PSYBooks, with notes that are more likely to contain sensitive information being in the clinical category, whereas notes that might be more administrative in nature (i.e., those pertaining to payments, claims, etc.) being categorized as admin notes. The various note types in PSYBooks are as follows:

Always in the Medical Record > Clinical category

  • Add/Edit Intake Form
  • Add/Edit Mental Status Exam (MSE)
  • Add/Edit Progress Note
  • Add/Edit Treatment Plan

Always in the Medical Record > Admin category

  • Add/Edit Adjustment
  • Add/Edit Authorization
  • Add/Edit Client Payment
  • Add/Edit Client Payment Allocation
  • Add/Edit ERA
  • Add/Edit Client Insurance
  • Add/Edit Insurance Payment Allocation
  • Add/Edit Resubmit Claim Note

Can be in Medical Record > Clinical or Psychotherapy categories (choice made by user):

  • Add/Edit Client
  • Add/Edit Session
  • Add/Edit Client Family
  • Add/Edit Client Medication

Always in the Psychotherapy (Personal) category

  • Add/Edit Open-Ended