Changes in Documentation After Implementing Open Notes in Mental Health Care: Pre-Post Mixed Methods Study

Abstract

Background: The practice of providing patients with digital access to clinical narrative documentation by health care professionals (HCPs) is known as open notes. In mental health care, this innovation has the potential to increase transparency and foster greater trust in the treatment process. While open notes may improve the quality of care and patient engagement, some HCPs are concerned that they may change the nature of clinical documentation and compromise its quality. Objective: This study aims to examine potential objective and subjective changes in clinical documentation following the implementation of open notes. Methods: Clinical notes written before and after the implementation of a patient portal with open notes function in 3 psychiatric outpatient clinics in Germany were collected. A total of 876 notes (453 prenotes and 423 postnotes) were rated on 16 linguistic features using a Likert scale. Differences were analyzed using the Wilcoxon signed rank test. In addition, 10 in-depth qualitative interviews with psychiatric HCPs were conducted and analyzed using reflexive thematic analysis. Results: Postimplementation significant differences were found in several linguistic features: Monoglossic (P=.002), incomprehensible (P