Practice Management System and Portal for Mental Health Professionals and their Clients

Notes in PSYBooks

/Notes in PSYBooks

All Patient Notes in ONE Place – You Don’t Have to Go Looking

Recently, a top journal in the field of Electronic Health Record (EHR) development posted this quote from an anonymous doctor who was dissatisfied with his EHR:

“I firmly believe this EHR makes important information difficult to find and interpret, and it is very inefficient.” He went on to say, “It creates superfluous and difficult-to-navigate notes and information that are not centralized. That makes it easy for care providers to disregard notes, and they often do. That affects patient safety. . . . It is difficult and arduous to document in the EHR, and providers’ efforts to do so still yield subpar results with erroneous, irrelevant information.”

This doctor is pointing out a very real problem inherent in some EHRs. However, he was referring to one of the "ONC Certified" EHRs which we've discussed previously. Those types of EHRS are inherently much more difficult to use than most EHRs that have been specifically created for the mental health professions, such as PSYBooks.

By |2021-04-29T21:56:01-04:00April 29th, 2021|Current, How To Choose an EHR, Notes in PSYBooks|Comments Off on All Patient Notes in ONE Place – You Don’t Have to Go Looking

Does the Open Notes Rule Apply to Me?

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 It is a continuation of the legislation originally enacted as part of the HITECH act of 2009 to promote EHR interoperability (with the ultimate goal being a national database for healthcare information on all U.S.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.

By |2021-02-23T01:17:23-04:00February 18th, 2021|Current, Notes in PSYBooks|0 Comments

Are We Becoming Outdated?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.

By |2019-04-29T18:19:43-04:00July 15th, 2017|Client Portal, Notes in PSYBooks, Why Use an EHR?|Comments Off on Are We Becoming Outdated?

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:

By |2019-04-10T12:25:45-04:00June 15th, 2014|Notes in PSYBooks|Comments Off on Your Personal Psychotherapy Notes (Hint: These Are NOT Part of the Client’s Medical Record)

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.

By |2019-04-10T12:28:15-04:00June 15th, 2014|Notes in PSYBooks|Comments Off on Medical Record Notes