Laura Groshong, LICSW, Director, Policy and Practice

The Impact of “Open Notes” on LICSW Practice

A recent message on the new rule called “Open Notes” created more questions than answers. This article is an attempt to clarify what is a somewhat regulatory, primarily semantic, and largely a continuation of record-keeping for LICSWs. Here is a list of FAQs about the Open Notes rule:

1. Where did the decision about Open Notes come from? Open Notes was part of the Interoperability section of the CURES Act which passed Congress last spring.
2. Why was the Open Notes rule created? There were two reasons. The first was that some information was being ‘blocked’ from patients, which is a violation of the Affordable Care Act and HIPAA. The second is that there was no incentive for hospitals to use interoperable medical records so there was not a complete medical record which all clinicians could access for a given patient.
3. What does the Open Notes rule change about patient access to the records? It is supposed to give patients more access to their records. The Health Information Act (HIT, 2004) and Health Insurance Portability and Accountability Act (HIPAA, 2003) already give patients the right to read their medical record but this was being violated (see#2). For LICSWs, there is a HIPAA rule that allows us to withhold the medical record if we think there is a chance it will be harmful to the patient to read it.
4. Does the Open Notes rule change the patient's, other clinicians', or an attorney’s right to see our psychotherapy notes? If psychotherapy notes are kept in a separate file from the medical record as stated in HIPAA, there is no change in psychotherapy notes being kept private for the use of the LICSW only. Psychotherapy notes cannot be used to keep required information out of the medical record.
5. How does the Open Notes rule change record keeping for LICSWs? The way that LICSWs make notes in the medical record should be the minimum necessary to show that the treatment is progressing according to the treatment goals which have been identified. If the medical record is more like process recordings, this is not the case. Keeping session notes limited to the demographic information, start and stop times, a short description of how the treatment goals are being met in SOAP notes or other format, and any new goals which have arisen are all that should be in the medical record.
6. Are LICSWs required to keep reports on the treatment in the interoperable medical record? So far this is not required but there may come a time when doing so will be required for insurance coverage. That is the goal of insurers at this time.

As LICSWs, we know that it is a clinical issue if the patient wants to see what we have written about them and it happens fairly rarely. We also know that it is a best practice, whether we are keeping notes for our own medical record or an interoperable one, to keep notes brief and connected to the treatment goals established for a given patient. If we stick to these practices, Open Notes should not pose a problem for clinical social workers.

Laura Groshong is the Director, Policy and Practice for the Clinical Social Work Association.