The term "Open Notes Rule" is a popular term coined to depict the legislation enacted by the 21st Century Cures Act that is more accurately referred to as the ONC's final program rule on Interoperability, Information Blocking, and ONC Health IT Certification (OpenNotes, 2020). It is a continuation of the legislation originally enacted as part of the HITECH act of 2009 to promote EHR interoperability (with the ultimate goal being a national database for healthcare information on all U.S. Citizens) and open access to records. The Open Notes Rule does NOT apply to PSYBooks users but there are some important things to understand about the current iteration of this legislation, partly in an attempt to help prepare us for what might be coming in the future.
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.
Each client’s chart has a Notes tab on the top right:
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:
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:
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.