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Opening Up Your Therapy Notes: An Orientation and Pragmatic
Guide to Practice

Enroll in the Online Self-Study course and complete it at your own pace.
1.5 CE hours available for behavioral health clinicians upon completion.

Opening Up Your Therapy Notes: An Orientation and Pragmatic Guide to Practice

What if the very thing you’ve been taught to guard—your therapy notes—could become your most powerful clinical tool? As laws and client expectations evolve, behavioral health professionals are at a pivotal crossroads: embrace transparency or risk eroding trust. This course reveals how sharing your therapy notes, even in the most complex cases, can deepen the therapeutic alliance, reduce stigma, and strengthen outcomes.

When clients can view their mental health notes, the stakes are high—but so is the potential for healing, clarity, and collaboration. This course offers the insight and strategies you need to navigate these changes with confidence and skill.

Enroll in the 1.5 CE Online Self-Study for $30

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Steve O’Neill, LICSW, BCD, JD, brings unmatched expertise to this course. As a longtime leader at Beth Israel Deaconess Medical Center and faculty at Harvard Medical School and Simmons University, Steve helped pioneer the OpenNotes movement in mental health. With decades of clinical, ethical, and teaching experience, he equips clinicians with a balanced, real-world perspective on what it means to share notes effectively and responsibly.

Steve’s teaching approach is pragmatic, thoughtful, and grounded in research and clinical experience. He shares not only lessons from years of implementation but also nuanced insights into clinician fears, patient responses, and strategies for effective documentation in complex situations.

Topics include the ethical and legal mandates of the 21st Century Cures Act, clinician concerns around patient misunderstanding and severe mental illness, the distinction between privacy and confidentiality, and methods for documenting challenging sessions. Real-world case studies and sample note language offer concrete solutions for clinicians unsure how to write notes that are both accurate and patient-friendly.

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Instructor

Steve O’Neill, LICSW, BCD, JD, is a social work ethicist, educator, and clinical leader with four decades at Beth Israel Deaconess Medical Center, where he served as Social Work Manager for Psychiatry, Primary Care, and Pain Management, and as Associate Director of Ethics Programs. A Harvard Medical School Fellow in Bioethics, he teaches within HMS’s Center for Bioethics and at Simmons University School of Social Work. Steve has been instrumental in shaping the NASW Code of Ethics and Professional Standards, and co-authored Legal Issues in Social Work (2004). A pioneer in healthcare transparency, he launched the first behavioral health OpenNotes program, giving patients direct access to their therapy notes. Now retired from his full-time roles, Steve continues teaching, consulting, and advancing ethical, patient-centered care.

Key Takeaways:

  • Understand OpenNotes in Practice: Learn from the successes and lessons of a groundbreaking mental health transparency initiative.

  • Reduce Misunderstandings and Improve Engagement: Write notes that invite clarity, safety, and collaboration—even with complex or high-risk clients.

  • Document with Confidence: Use documentation strategies that protect therapeutic integrity while building trust.

Why this course?

  • Cutting-Edge Expertise: Learn from the mental health leader who helped launch the first-ever open therapy notes program.

  • Ethical and Clinical Relevance: Addresses both legal requirements and therapeutic realities—an essential combo for today’s clinicians.

  • Support You Can Use: Gain ready-to-apply tips, real scripts, and documentation templates that make your job easier and your practice stronger.

Learning Objectives:

  • Describe the experience/research outcomes of implementing OpenNotes within mental health practices.

  • Understand the implications of the Cures Act, especially around ‘information blocking,’ for mental health practice.

  • Describe documentation strategies that may assist greater patient engagement and trust within clinical practice.

Discover how transparency, when done thoughtfully, isn’t a risk—it’s a radical opportunity. Join this course and gain the skills, language, and confidence to open your notes and elevate your care.

Add this course to your cart to begin learning instantly.

This is a non-interactive, self-study course. Instruction consists of 1.5 hours of video instruction and a post-test.

Enroll in the 1.5 CE Online Self-Study for $30

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Availability: From the time of registration, you have six months to access the coursework.

Who Should Attend: This course is intended for clinicians who provide behavioral health services.

Teaching Methods: This is a non-interactive, self-study course. Teaching methods for this course include recorded lectures, videos, a post-test, and a course evaluation.

How to attend: Directions for completing a course can be found by clicking here.

This program was recorded on July 30, 2021.

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