I’m trying to keep up with the laws, news, events, etc. but it’s so much going on that’s affecting healthcare that I may be delayed but happily not too far off! This post is actually perfect timing for health providers to get themselves together and prepare for the future.
A law was recently passed on Nov. 2 to give patients access to reading their health records, which is different from the access with HIPAA that can take longer to obtain. This law enables immediate access to the patient’s notes, which some providers may need to brace for. Thankfully, the law got delayed until next year due to COVID so it’ll give people plenty of time to adjust or improve their charting. Information about the law is at the bottom.
I believe in more transparency and patient rights because it’ll help the client be more engaged in their care. I didn’t always feel like this. Some patients are so hostile and unpredictable that I worried about my own safety and the safety of others. However, I’ve learned quickly that documentation is KING and many times my writing has saved me and I’ve been in some rough situations especially working in critical care.
Long story short, chart as if the patient is reading your words. There are other examples; chart like you’re talking to a loved one or chart how you want someone to talk to you. In other words, chart in a way that’s encouraging and shows progress.
Speak and write their healing into existence.
So do NOT chart, a patient called me a “turtle face roach &*#^G@” and all the expletives… unfortunately, it does not build a case, and very often people will ask what did the provider do to cause this type of reaction. Try to use the words verbally aggressive or patient is irritable, agitated, restless, non-adherent with proper communication, lacking and violating verbal boundaries…etc. One day I will give you a list of my insanely “safe words” lol
However, true threats and acts/words of violence are different and belong in the MIDAS or a police report. Also, note how we don’t put gloating remarks in the patient chart as well i.e. patient said “I’m the best provider and a queen”. It just doesn’t belong so don’t put insults or compliments in the chart. And please don’t forget about the power of social media. If you write something crazy in the patient’s chart and it gets a screenshot or ends up on Twitter it can be a colossal disaster…
With patient documentation, try to keep the notes consistent and OBJECTIVE, avoid things inappropriate, rude, catty, disgusting…sometimes the stuff I read is triggering and I’m very mindful of making sure not to trigger others, including myself! A post in Psychiatric Times mentioned several concerns about disclosing clinical notes but it goes back to remaining objective and neutral. The article is correct about how notes don’t give the whole picture or reflect the current status but that’s with everything so if I had a choice, I want the picture to be GOOD. That’s why notes should be written in a way that’s empathetic, encouraging, and positive. For example (from that particular link):
A medical trainee may include psychodynamic speculations or may begin progress notes with unforgiving clinical language, such as “oddly related 29-year-old unemployed, unmarried, childless female with a severe personality disorder arriving after a failed suicide attempt.” -Psychiatric Times [and that’s true, simply the tone can create a negative picture.]
I would’ve worded the situation like this: Client is unemployed, discussed current goals for financial resources including consulting the social worker for government assistance and educational opportunities. Client mentioned depression and recent SI concerns that were related to mood and behavior instabilities. She currently reports a lack of sleep, uncontrolled thoughts, and increase appetite. Client mentioned that family and friends continue to be a solid social support and client also copes by writing in her journal. Client expressed taking care of her mother is one of the main reasons to continue to improve herself and utilized mental health services. She adheres to medication and therapy….Client is currently taking Luvox…
Trust me. WORDS can make or break a situation and all my notes are similar to this -with the patient’s progress, ideals, concerns, plans, and goals. However, I want to be very clear about this, there are no national standards about how to document so it’s no super right or wrong way. If somebody’s notes are unprofessional or sloppy, all you can do is avoid the bad habits. Good charting is simply an expectation but it could be a great lifesaver, especially in lawsuits. Overall providers should be aware that if you choose your words wisely, you can avoid bigger problems.
Correction: I actually did write something about charting a long time ago but it was general for nursing students. I’ll try to post something about charting, specifically for mental health in the future <- there it is! and here are some extra posts:
- Good Charting Tips: quick tips and what to avoid plus a PDF at the bottom about documentation by ANA
- Medical Abbreviations & 8 Common Charting Mistakes
Federal Rules on Interoperability and Information Blocking, and open notes…
This web page is not official technical or legal advice. State laws around data release may not superseded by the 21st Century Cures Act. Consult with your organization’s Health Information Management, compliance, legal, finance, and public affairs teams to find out how it applies to you.
The program rule on Interoperability, Information Blocking, and ONC Health IT Certification, which implements the 21st Century Cures Act passed in 2016, requires patients be provided access to all the health information in their electronic medical records without charge by their healthcare provider beginning April 5, 2021.
OpenNotes is invested in the Cures Act because clinical notes are among the information that must not be blocked—and thus be made available to patients.
What notes must be shared?
The eight (8) types of clinical notes that must be shared are outlined in the United States Core Data for Interoperability (USCDI), and include:
- consultation notes
- discharge summary notes
- history & physical
- imaging narratives
- laboratory report narratives
- pathology report narratives
- procedure notes
- progress notes
Clinical notes to which the rules do not apply:
- Psychotherapy notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record. Note: Clinicians and organizations are required to share medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
- Information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding.
What is the timeline for when these new rules go into effect? Under this new rule, clinical notes must be shared by health systems by April 5, 2021, and shared with a patient’s 3rd party application (e.g., downloaded to a smartphone) by October 6, 2022.
Are there any exceptions to the Rules? There are complex situations in which information can be blocked—and these are called Exceptions. Unless one of the Exceptions applies, clinical notes must not be blocked. A group called actors are referred to throughout the rule. Actors include:
- Health care providers
- Health information networks or health information exchanges
- Health IT developers of certified health IT (e.g., electronic health record vendors)
Featured below are the exceptions outlined by the final rule, which fall into two categories (source).
More Information
- New for health professionals in 2021, extra great information about documentation by Open Notes
- Open Notes are Delayed Until April by Med Page
- Riverside Psychiatric Medical Group settles with HHS OCR to resolve a potential HIPAA Right of Access violation. The $25,000 settlement is the tenth of the OCR patient access initiative by Health IT Security: the consequences of delaying a person’s access to their medical records.
- Your Patient Is Now Reading Your Note: Opportunities, Problems, and Prospects by The American Journal of Medicine
- What Providers Must Know About Patient Access to Clinical Notes by Patient Engagement Hit
