Open Notes in Psychiatric Care: Debunking Myths, Ensuring Confidentiality, and Embracing Telehealth
Welcome back to the Sit and Stay Podcast blog! This post continues our look at Open Notes—an initiative that grants patients easy online access to their clinical records. Open Notes gained traction in part due to regulations like the 21st Century Cures Act, which promotes more transparent sharing of health information. Although it can sound straightforward, this approach still raises questions about confidentiality, therapeutic relationships, and legal responsibilities.
Why does this matter? Sharing notes can support clearer communication between providers and patients, helping clients better understand their diagnoses, treatment options, and next steps in care. However, some practices remain wary of potential misunderstandings, privacy issues, or legal complications. Below, we spotlight common misconceptions, describe strategies for documenting sensitive information, discuss real-world concerns (including insurance complexities), and consider the implications of telehealth and AI for the future of mental health care.
Image: Unsplash
Open Notes in Psychiatric Care: Common Myths and Misconceptions
A frequent worry is that when patients have direct access to their psychiatric records, they might file more lawsuits, lose trust in providers, or experience undue distress. However, both research findings and everyday experiences in clinical settings challenge these fears—suggesting that transparent documentation can actually foster stronger communication and understanding.
Legal Concerns
Many clinicians worry that allowing patients to see detailed notes will lead to a surge in malpractice claims. Yet, multiple studies and anecdotal evidence from clinics show that liability rates have stayed relatively stable. Where concerns do arise, they typically relate to broader systemic issues—such as miscommunication or administrative errors—rather than transparency in and of itself. By carefully documenting each session and providing context for diagnostic terms or treatment decisions, providers can maintain accurate records that support their work while reducing any confusion that might otherwise trigger disputes.
Therapeutic Relationship
Some fear that seeing terms like “psychosis” or references to past abuse could upset or alienate individuals in therapy. In practice, many clinicians find that Open Notes motivate them to use clear, empathetic language and proactively discuss sensitive details with patients, which can actually strengthen rapport. For instance, if a patient reads a challenging term in their record and asks questions, it becomes an opportunity to clarify meaning, address concerns, and emphasize the next steps in treatment. When approached with openness and patience, this level of transparency often builds trust rather than damaging it.
Privacy and Confidentiality
Another misconception is that Open Notes automatically undermine privacy, especially in mental health settings where sensitive topics like trauma or substance use may appear regularly. In reality, most electronic health record (EHR) systems allow clinics to mark highly personal or protected information as “confidential” or “locked.” This includes mandated reporting details—such as child or elder abuse disclosures—as well as other specifics deemed sensitive by both patient and provider. Limiting highly detailed content in the public-facing note while still documenting factual elements can protect confidentiality and preserve the therapeutic process.
———
Example: Adolescent Access
Some organizations grant teenagers (usually between 13 and 17) a partial view of their health records. Parents might still see scheduling details or billing statements without reading every note in the chart. Though it adds complexity, this approach allows teens a sense of autonomy while respecting parental oversight.
Image: Unsplash
Balancing Transparency in Sensitive Mental Health Documentation
Open Notes can prompt questions about disclosing delicate information without harming rapport. Here are three scenarios:
Psychosis and Other Conditions
Instead of labeling someone “psychotic,” a provider can list the specific beliefs or statements that emerged in session. A brief remark that there was an agreement to revisit certain topics at a later time tends to feel less dismissive than definitive labeling.
Trauma, Sexual Abuse, and Mandated Reporting
An entry might simply say “spent time exploring previous abuse,” avoiding graphic content. If child protection services or another agency must be contacted, those details are usually kept in a separate note or addendum not visible through an online portal.
Substance Use
Writing “patient reports daily use of [substance]” offers enough context to guide treatment. This style of documentation preserves accuracy and can invite collaborative problem-solving.
———
Real-world situations can involve patients who hold delusional beliefs or dispute their substance misuse. Focusing on what was said, the outcome of the session, and any follow-up plan maintains both accuracy and respect for the individual’s viewpoint.
Image: Unsplash
Legal and Ethical Considerations for Implementing Open Notes
Although transparency has its benefits, mental health practices must address several legal and ethical factors to keep both patient welfare and regulatory requirements at the forefront. Below are two core considerations, along with additional points to ensure responsible Open Notes adoption:
1. Data Security
Access control is essential, allowing only authorized individuals—such as the patient and relevant clinical staff—to view or modify records. This typically involves secure login protocols such as multi-factor authentication and strong password requirements within the patient portal.
Patient education is also critical; many users do not fully grasp the importance of password confidentiality, so clinicians or staff often emphasize how crucial it is to avoid sharing login credentials, especially if the patient relies on family members or caregivers to navigate online systems.
In addition, practices must meet HIPAA and local privacy regulations by using protective features like automatic session timeouts, encrypted messaging, and routine system audits that can detect unauthorized access.
2. Documentation of Safety Concerns
When there is a potential risk of harm—whether to the patient or to others—providers maintain a clear record of their assessment and any steps taken to manage the situation, such as contacting emergency services or arranging inpatient care. This documentation not only assists in coordinating effective treatment but also demonstrates due diligence from a legal standpoint.
In cases involving child or elder abuse, details are usually noted in broad terms within the Open Note, while more specific or graphic information is kept in a separate, protected area of the record to safeguard privacy. If patients read in their chart that they may be at elevated risk for self-harm or harming others, providers should be prepared to discuss these findings in a direct yet empathetic manner, explaining the clinical reasoning behind certain terms or labels and clarifying any recommended interventions or next steps.
3. Informed Consent
In many practices, informed consent is woven into patient intake or orientation workflows, making sure individuals know the purpose of Open Notes, the kind of information that may appear, and how they can raise questions or request changes. This transparent approach helps manage patient expectations and reduces the likelihood of confusion later on.
4. Special Populations
Certain groups—such as minors, those with guardians, or individuals under court-mandated care—require more nuanced record-sharing strategies. Confirming which parts of the chart can be shared and clarifying consent protocols ensure that legal requirements are met and ethical boundaries remain intact.
5. Ongoing Staff Training
Front-desk teams, clinical providers, and administrative personnel benefit from regular updates on software features, privacy regulations, and mandated reporting obligations. By keeping everyone current, practices minimize the risk of breaches, errors, or oversights that could undermine the benefits of Open Notes.
Image: Unsplash
The Future of Telehealth and AI in Psychiatric Records
The growth of telehealth has dramatically changed how mental health services are delivered, offering greater flexibility for both clients and clinicians. At the same time, artificial intelligence (AI) tools are beginning to transform clinical documentation, from transcription to drafting treatment notes. While these developments promise efficiency and wider access, they also raise questions around accuracy, responsibility, and legal accountability.
Accuracy and Responsibility
Even when AI systems generate initial drafts of clinical notes, human oversight remains essential to catch any errors or omissions. For example, an automated transcript may misinterpret a key symptom or incorrectly summarize a conversation about risk factors, potentially derailing treatment plans. By reviewing AI-generated notes carefully, clinicians confirm that the final record accurately represents the patient’s presentation, interventions, and follow-up steps. Skipping this crucial step of human review could invite liability concerns if inaccuracies lead to inappropriate care decisions or misunderstandings about a patient’s history and current needs.
Legal Boundaries
As AI tools grow more advanced—potentially integrating voice recognition, natural language processing, and predictive analytics—questions about liability become more complex. If an automated system introduces or overlooks critical information in a patient’s record, determining who bears responsibility can be challenging. In the future, insurers, licensing boards, and the legal system may look into whether accountability lies with the software vendor, the supervising clinician, or both. Practices that rely on AI-based documentation will likely need clear policies delineating how notes are reviewed and who makes final decisions. Establishing these guidelines early helps maintain legal clarity while maximizing the benefits of AI-driven efficiency.
———
In the larger context of telehealth, AI-powered platforms may also assist with real-time decision support or symptom tracking, highlighting trends and risks that might otherwise go unnoticed. However, the need for clinicians to interpret these insights and apply clinical judgment remains central to ethical and effective mental health care. By blending human expertise with advanced technology, psychiatric providers can streamline workflows and potentially enhance patient outcomes—provided they stay attentive to accuracy, privacy, and professional accountability.
Image: Unsplash
The Mental Health Business Moment of the Week
This episode touches on the confusion surrounding insurance “carveouts,” where one insurance company delegates mental health coverage to another partner. Often, a patient’s card doesn’t clearly indicate this arrangement, leading to billing surprises or denied claims. Practices that examine each patient’s coverage details upfront—and ask specifically about any extra mental health partners—help reduce confusion, unexpected costs, and unnecessary administrative back-and-forth.
Conclusion
Open Notes can serve as a valuable tool for transparency in psychiatric care, provided clinicians address potential pitfalls. From persistent myths about legal hazards to the delicate process of writing notes on trauma, substance use, or psychosis, a balanced style of documenting and clear communication protect both patient and provider interests.
Open Notes are reshaping the way mental health professionals and clients interact. By writing records in a thoughtful way, discussing terminology directly, and remaining mindful of both privacy and legal obligations, clinicians can share crucial information without sacrificing client welfare.
Have a question or topic you’d like us to explore? Contact us at sitandstay@ripsytech.com.
And don’t forget to subscribe to the Sit and Stay Podcast for more insights on running a thriving mental health practice.
Looking for a health record solution that simplifies your workflows and supports your practice’s business needs?
RipsyTech has your back. Schedule a demo with us today.
