Description 

Mental health documentation has traditionally been classified as protected and kept away from the eyes of other providers, patients and to some extent even the law, in the case of psychotherapy process notes (1). However, on April 5th, 2021, Congress passed the 21st Century Cures Act, one of its provisions being that “healthcare providers give patients access without charge to all the health information in their electronic medical records without delay” (2)-mental health documentation included. Sharing mental health notes with patients remains a sensitive issue, largely due to clinicians’ fears that review of this content might cause harm, specifically psychiatric destabilization (3). However, studies performed over the last decade have shown the benefits of open notes including improved patient satisfaction and safety as access to their medical record has helped patients understand their medications and feel more in control and comfortable with the treatment plan (4).   The issue with documentation in health care, and especially in psychiatry, is the used of terms that are not accessible to the average member of society and occasionally even stigmatizing for particular patient populations (5). Considering the CURES act, clinicians might find themselves at a crossroads between wanting to meet the medico-legal and billing requirements of documentation and not wanting the therapeutic relationship or the clinical status of their patients to deteriorate when these notes are shared without any “filtering” or opportunity to process the information jointly.   While some leaders in the field have published guidelines for documentation such as Posada et al.’s 2021 article (6), theoretical guidance is not enough and practical workshops and note writing exercises are needed to improve this new skill.   In this session we aim to empower the audience with recovery- oriented language and tools to produce documentation that is accurate, timely and not cumbersome, and at the same time helps bridge the gap between patients and providers and opens the conversation about mental health diagnoses and treatment. The co-facilitators of this session have experience participating in and running the Peer Advisor program at Columbia University- a partnership between people with lived experience and public psychiatry fellows and have conducted several workshops on recovery- oriented documentation as part of this program. The insight gained from years of working directly, in a non-hierarchical relationship, with people with lived experience will be shared with the audience through an interactive note writing exercise.

Format 

Recorded webinar.

This content was recorded during the APA 2023 Annual Meeting.

Learning Objectives 

1. Understand the provisions of the Cures Act and how it impacts access to mental health records.
2. Name 3 benefits of open notes for patients and providers.
3. Re-write a progress note from a patient centered and recovery-oriented perspective.

Target Audience 

Residents/Fellows, Psychiatrists, Psychologists

Estimate Time to Complete 

Estimated Duration: 1.5 hours
Program Start Date: May 1, 2025
Program End Date: May 1, 2028

How to Earn Credit 

Participants who wish to earn AMA PRA Category 1 Credit™ may do so after completing all sections of the course including the evaluation. After evaluating the program, course participants will be provided with an opportunity to claim hours of participation and print an official CME certificate (physicians) or certificate of participation (non-physicians) showing the completion date and hours earned. 

Continuing Education Credit  

In support of improving patient care, the American Psychiatric Association is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. 

The APA designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. 

Faculty and Planner Disclosures 

The American Psychiatric Association adheres to the ACCME’s Standards for Integrity and Independence in Accredited Continuing Medical Education. Any individuals in a position to control the content of a CME activity — including faculty, planners, reviewers or others — are required to disclose all relevant financial relationships with ineligible entities (commercial interests). All relevant conflicts of interest have been mitigated prior to the commencement of the activity. 

Instructors 

• Maria Bodic, MD
• Ludwing Florez Salamanca, MD
• Peter Steen, MD
• Nubia Chong, MD

Planners  

• Vishal Madaan, MD, Chief of Education and Deputy Medical Director at the American Psychiatric Association.

Accessibility for Participants with Disabilities 

The American Psychiatric Association is committed to ensuring accessibility of its website to people with disabilities. Please contact the American Psychiatric Association at 202-559-3900, if you require assistance seven (7) business days prior to the start of a live webinar. 

Technical Requirements 

This internet-based CME activity is best experienced using any of the following: 

• The latest and 2nd latest public versions of Google Chrome, Mozilla Firefox, or Safari 
• Internet Explorer 11+ 

This Web site requires that JavaScript and session cookies be enabled. Certain activities may require additional software to view multimedia, presentation, or printable versions of the content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Acrobat Reader, Microsoft PowerPoint, and Windows Media Player. 

Optimal System Configuration: 

• Browser: Google Chrome (latest and 2nd latest version), Safari (latest and 2nd latest version), Internet Explorer 11.0+, Firefox (latest and 2nd latest version), or Microsoft Edge (latest and 2nd latest version) 
• Operating System: Windows versions 8.1+, Mac OS X 10.5 (Leopard) +, Android (latest and 2nd latest version), or iOS/iPad OS (latest and 2nd latest version) 
• Internet Connection: 1 Mbps or higher 

Minimum Requirements: 

• Windows PC: Windows 8.1 or higher; 1 GB (for 32-bit)/2 GB (for 64-bit) or higher RAM; Microsoft DirectX 9 graphics device with WDDM driver; audio playback with speakers for programs with video content 
• Macintosh: Mac OS X 10.5 or higher with latest updates installed; Intel, PowerPC G5, or PowerPC G4 (867MHz or faster) processor; 512 MB or higher RAM; audio playback with speakers for programs with video content 

For assistance: Contact educme@psych.org for questions about this activity | Contact learningcenter@psych.org for technical assistance