Photographers and cartoonists commonly portray therapists holding a notepad and pen as they sit next to clients. There is some truth to this stereotype — therapists often take notes during therapy sessions to remember details or record their thoughts.
Therapists may also type their handwritten notes into an electronic health record (EHR) system after each session. Some therapists might reach for their notepad simply out of habit.
In any case, note-taking is an essential part of a behavioral and mental health career. Behavioral health notes help counselors treat patients effectively, and they are often required for insurance reimbursement.
However, it's not a requirement to handwrite notes. Handwritten notes can slow therapists down and add to their documentation burden. They can also take time away from clients.
If you're a behavioral health professional who handwrites notes, you may want to explore more efficient note-taking options. In this post, we'll look at reasons to put down your pen and paper and take electronic behavioral health notes instead.
Can Behavioral Health Notes Be Handwritten?
Behavioral health notes can be handwritten, however, there is a lot to consider before choosing to handwrite notes. First, whether it's a good idea to handwrite a mental health note depends on the type of note you plan to take. For example, you may feel more comfortable handwriting psychotherapy notes.
Psychotherapy notes are kept separately from a client's records. They are your private notes that may include the thoughts, ideas, or feelings you have during a session.
Psychotherapy notes are optional, so you can use any note-taking method or format you wish. Depending on your preferences, you might find it easier and faster to type than handwrite psychotherapy notes.
All other documentation, including progress notes, should not be handwritten. Progress notes are shareable and may be audited or subpoenaed. Clients also have a right to read their progress notes. Progress notes need to be accurate, legible, and easy to understand.
If you type progress notes, you reduce the risk of misunderstandings or other issues related to accuracy and readability.
Disandavantages of Handwritten Notes.
Healthcare is transforming into a digital industry. More health care providers are embracing digital tools, such as EHR systems to improve patient outcomes. For example, according to statistics from 2017, almost 9 in 10 office-based physicians implemented an EHR system. An EHR system may include features such as documentation management, billing integrations and a telehealth platform.
In addition, digital tools like EHRs increase interoperability and patient access to their medical records. Both of these elements are critical to improving health outcomes and patient engagement. Today, patients expect personalized health care, and they want easy digital access to their medical records, including their mental health notes.
Handwritten notes do not fit into the digital healthcare transformation for many reasons. Here are some disadvantages of handwritten mental health notes and reasons to become a paperless practice:
- Time-consuming: Writing behavioral health notes should take up to 10% of your time, and the other 90% should be spent on patient care. If you're handwriting progress notes before entering them into your EHR, you're adding an extra step to your workflow. If you only keep handwritten notes in your practice, you don't get to access an EHR's note-taking templates, which can help you complete documentation tasks in less than five minutes.
- Worrisome to clients: Handwriting is a slower process than typing or clicking on pre-formatted data. If you prefer to take handwritten progress or psychotherapy notes during sessions, you'll spend a greater portion of your time writing, and this could make clients feel as if you aren't giving them your full attention. As a therapy best practice, you should minimize note-taking during sessions as much as possible.
- Repetitive: Writing progress notes for regular clients can feel like a tedious process when certain elements are unlikely to change from one session to the next. For example, handwriting details about a client's diagnosis, symptoms, or appearance can get repetitive. Using an EHR system allows you to click on data and quickly add details to progress notes.
- Inaccurate: Since handwriting is a slower process than typing, it may be challenging to keep up with specific details a client shares. For example, if a client speaks rapidly about symptoms and important dates, you need to write fast. Writing too quickly could lead to errors, missing information, or sloppy handwriting — which can be hard to interpret later on.
- Lack of security: Handwritten notes can easily get lost or misplaced, which puts patients' privacy at risk. As a behavioral health professional, you are obligated to protect your clients' privacy, whether you handwrite notes or store them electronically. With handwritten notes, this may mean keeping them in a locked file cabinet, but even that may not be enough to protect files from theft, fires, or other disasters.
- Difficult to correct: If you're typing a note and notice you misspelled a client's name or entered the wrong date of birth, you simply need to hit the backspace key and start over. If you handwrite therapy notes, mistakes are harder to change unless you use a pencil, which presents another problem — pencil marks are too easy to erase. It's better to type notes from the start to avoid creating documents that contain scribbles or crossed-out information.
- Harder to organize: Handwritten notes need to be stored in an organized manner so you can easily access them when you need to. This level of the organization takes time and continual maintenance. Digital notes are stored conveniently in one place and are much easier to access and keep organized.
- Impedes continuity of care: If you plan to go on vacation or refer your client to a different counselor for other reasons, you probably don't want to hand the new therapist handwritten notes. Handwritten notes are more difficult to read than typed documents, and you may worry about them getting lost as they travel from one place to the next.
- Reduces staff efficiency: Sincehandwritten documents are typically harder to read, your staff members may have to spend extra time in the workday deciphering progress notes or other information. They'll also have to locate the notes in a client's paper file, which can be a time-consuming task if notes aren't kept organized.
How Handwritten Notes Present Confidentiality Issues
Just like electronic formats, handwritten notes must meet the standards set by the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. If a covered health care provider fails to comply with the Privacy Rule, they may be subject to a fine, or in some cases, imprisonment. Even if your practice isn't considered a covered entity under HIPAA, behavioral health professionals have an ethical obligation to protect client confidentiality.
Handwritten notes make it more challenging to maintain client confidentiality for several reasons. Unlike electronic documents, which can only be accessed by authorized users, anyone can pick up and read a handwritten note. It's also easy for handwritten notes to leave an office and get into the wrong hands.
For example, in 2014, a Connecticut call center employee left work with a notepad containing protected health information of over 400 customers. The employee left the notepad in a public space, failing to comply with HIPAA and putting customers' security at risk. Consider that employees might jot down patient information on a piece of paper and put it in their pocket. They might forget that they have protected health information in their pocket and take it home with them for anyone to see.
Handwritten notes make it easier to breach confidentiality laws within a healthcare facility as well. For instance, a staff member might forget to file a client's record and leave it out in the open. Likewise, employees might not shred handwritten notes when they're supposed to, or they might drop off paper documents in an unsecured area. Something as simple as forgetting to lock a file cabinet could lead to a HIPAA violation.
Should You Be Using Behavioral Health Note Software?
Electronic mental health notes offer enhanced security and help keep practices HIPAA-compliant. In today's healthcare industry, electronic notes also play a vital role in delivering high-quality patient care. Here are reasons all practitioners should use note-taking software to create and maintain clients' records:
- Save time: Using note-taking software can drastically reduce the amount of time you spend completing documentation tasks. Electronic note software is often customizable, so you can create templates, checkboxes, or drop-down menus that suit your practice. You can quickly write progress or psychotherapy notes during or after appointments using customized point-and-click templates.
- Promote care coordination: Electronic note-taking makes it easier to communicate with other health care providers. For example, you can use secure therapy note software to exchange medication information or medical histories with a client's primary care physician. This can help you provide safer, holistic care because you'll have a better understanding of each client's health overall.
- Share your notes with clients: Patients are becoming more involved in their health care, and part of this is due to the healthcare industry becoming more digitized. For example, psychologists who use EHR software will soon need to provide patients digital access to their notes under new federal rules. Even if these rules do not apply to your practice, you may still want to share notes with your clients and encourage them to be more engaged in their treatment. Electronic note-taking makes it easier to share legible notes that clients can understand and benefit from.
- Comply with privacy laws: Note-taking software, such as EHR systems, often include advanced security measures. EHR software should be certified by the Office of the National Coordinator for Health Information Technology (ONC) and offer password protection, audit trails, and data encryption. These features can help you establish HIPAA compliance, so you won't have to waste time or energy worrying about security issues.
- Improve your services: Electronic notes can help your practice run more efficiently and get all staff members on the same page. As a result, you can provide high-quality care to your clients and improve their health outcomes.
If you want to enjoy the benefits of creating digital mental health notes, your next step is to choose the right software for your practice. If you want to maximize your practice's efficiency and improve operations overall, consider implementing comprehensive EHR software.
EHR systems go beyond typical office management software. If you choose an EHR designed for the behavioral health field, you can use the system to complete all your documentation tasks, including note-taking, submitting insurance claim forms, and sharing notes with patients. With EHR software, you can update your practice, keep pace with other health care providers, and most importantly, meet or exceed your clients' expectations.
Making the Most of Your Time With ICANotes
When selecting an EHR for your behavioral health practice, you have a lot to consider. Not all EHRs or practice management systems reduce documentation time or solve workplace inefficiencies. Before choosing an EHR, identify your priorities and look for software features that will meet your needs and help you reach goals.
ICANotes is comprehensive EHR software designed to meet the needs of busy behavioral health professionals. Each feature was created to increase efficiency and decrease the documentation burden that mental health providers face. By incorporating ICANotes into your practice, you'll have access to the following features and benefits:
- Customizable note-taking templates: ICANotes makes it easy to create, share, and manage electronic documents securely. Using customizable templates and automated data population, you can quickly and accurately write progress notes and conduct assessments.
- Patient portal: Your clients can use the patient portal to access their medical history, confirm or cancel appointments, complete intake forms, request refills, and communicate with you electronically. The patient portal decreases your workload and improves patient satisfaction.
- Billing solutions: With flexible, integrated billing solutions, you can create superbills, process payments, and submit insurance claims all in your EHR.
- Telehealth capabilities: ICANotes offers the option to add telehealth capabilities to your plan. Using the telehealth feature, you can conduct HIPAA-compliant video sessions and offer your services from anywhere.
- E-prescribing: With the e-prescribing feature, you can send accurate and legible prescriptions directly to a pharmacy from your office. E-prescribing makes it much easier and safer for patients to get the medications they need.
Request a Free Trial of ICANotes Today
Note-taking is a part of the job as a behavioral health professional, but it doesn't need to take time away from your clients. ICANotes can help you save time, reduce your documentation burden and write better notes. To try ICANotes, request your free trial or contact our support team. If you'd like note-taking tips for therapists or more industry information, check out our blog.
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.