Beginning on April 5, 2021, a federal ruling will necessitate that clinicians allow virtual access for patients to view their notes. These notes are to be provided free of charge to the patient.
This ruling is part of the 21st Century Cures Act signed into law on December 13, 2016. While patients have maintained the right to view their medical records since the enactment of the Health Insurance Portability and Accountability Act (HIPAA) in 1996, the process often involved filing paperwork, waiting for long periods and paying fees. The Cures Act aims to improve this process by giving patients fast and free virtual access to their records and patient notes.
Though the regulation was initially set to take effect on November 2, 2020, federal officials have extended the compliance deadline to April 5 to accommodate facilities overwhelmed in the midst of the COVID-19 pandemic.
The Benefits of Sharing Notes With Patients
Sharing notes and records with patients allowed them to engage in their behavioral health care plan and manage their care. Accessing what a clinician has written benefits patients by allowing them to revisit what was said during their appointment. This is especially true for patients who may be unable to recall what was said regarding medication changes.
In a study published in 2020, clinicians who encouraged their patients to read through their notes online found that 18% of their clients did bring up their notes during subsequent visits, showing a greater vested interest in their personal care.
Further, access to clinician's notes and records allows patients to check for inaccuracies. While a clinician may have many notes to look at and review, patients only have one set and are more likely to catch mistakes. With fast and easy patient access, these mistakes can be caught and corrected quickly.
Impact of Regulations on Clinical Practices
As a clinician, you may be wondering if your notes are mandated to be viewed. In most cases — with a few important exceptions — the answer is probably yes. Progress notes created by prescribers, therapists, and nurses are all included in this ruling.
While this regulation update can benefit patients, it will pose some challenges to clinical practices in the way they record notes. Sharing notes with patients means clinicians must spend more time documenting and making the notes accessible for clients to understand.
During a study that included 1,628 clinicians, 36% reported spending more time on documentation when they knew clients would have access. They reported making specific changes to the way they documented their notes, including adjusting language that may seem disparaging to the patient.
ICANotes Can Help You Comply
The new open-note regulations associated with the Cures Act may create additional pressure on the already labor-intensive process of documenting accurate information in client notes. However, at ICANotes, our electronic health record (EHR) software is ready out of the box to help your behavioral health documentation meet compliance standards.
We have tailored our statements to be considerate of patients while providing clear and concise information. Our software helps you create notes that are professional and accurately reflect the behavioral health and primary care symptoms your patient is experiencing.
You can get started by requesting a free trial of our behavioral health EHR software.
Clinical Director October has been a Registered Nurse for over 15 years. She is board certified in Mental Health and Psychiatric Nursing. She holds a Bachelor of Arts from the University of North Carolina at Greensboro. She also graduated with bachelor and master degrees in Nursing from Western Governors University.