New Rules Affecting Your Notes: Should You Panic About the New “Open Notes” Rule?

Many therapists have contacted me after hearing about a federal rule that was to go into effect today.  It seemed to state that we had to share all our notes with a client immediately after a session.

The “Information Blocking” rule of the 21st Century Cures Act, passed in 2016, was indeed slated to go into effect November 2, 2020. Referred to as “Open Notes,” it stated that notes had to be made immediately available to clients after a session. For psychotherapists, these would include progress notes, consultation notes, and discharge summaries.

But after some research, and after attending a webinar presented by my favorite technology gurus at PersonCenteredTech.com (PCT), I have concluded there are five reasons not to panic:

1. The basic rights here are not new.  Clients have long had the ability to view their notes, and in 2000 HIPAA codified this right.  This new rule is designed to make it easier for clients to view their notes.
2. Implementation has been postponed until April 5, 2021, according to the Department of Health and Human Services, to give providers more time to comply.
3. Most therapists won’t need to make changes.  According to Person Centered Tech, while the rule applies to all of us, it mostly affects providers using Electronic Health Records (EHR) certified by the Office of National Coordinator for Health Information Technology (ONC).   These professionals will have to provide the technical capability to make notes immediately available to clients (ex. via client portal).  But most of us who think we are using an EHR are actually just using a practice management program (e.g. SimplePractice, TherapyNotes, TherapyPartner, or Theranest) which don’t have that capability. “If you don’t have the technical capability to make notes available immediately, you are not violating the rule by not making them available immediately,” says Roy Huggins, founder of Person Centered Tech.
4. HIPAA-defined “psychotherapy notes” are exempt from the rule (for more on psychotherapy notes, see my article here).
5. If you keep paper notes, you can relax.  There is nothing new to require you to keep electronic records.

To listen to the replay of Person Centered Tech’s webinar on the “Open Notes” rule, visit https://personcenteredtech.com/federal-open-notes-rule-discussion/

It is important to remember that clients can request their session notes at any time.  To read my article on this topic, which outlines some practical and philosophical shifts that you might consider making as you keep this in mind, click here.