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

Description

This course does not offer CE Credits. The same course is available for purchase and offers 1.5 clinical CE hours for behavioral health clinicians.  See "related products" below.

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.

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.

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.

Format and Access

This is a non-interactive, self-study course and consists of over 1.5 hours of video instruction and an evaluation.

Course Details

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: 

Course access and completion instructions.

Instructor and Disclosures

Instructor

About STEVE O’NEILL LICSW, BCD, JD  

Steve was the Social Work Manager for Psychiatry, Primary Care, Pain Management, and Infectious Disease as well as the Associate Director of the Ethics Programs at Beth Israel Deaconess Medical Center where he has worked for 40 years.  He completed a Fellowship in Bioethics at Harvard Medical School, is a Clinical Instructor in the Department of Social Medicine and on the Teaching Faculty within the Center for Bioethics at Harvard Medical School.  Steve is also an Adjunct Professor at Simmons University School of Social Work.  He chairs the National Association of Social Work’s Massachusetts Chapter’s Committee on Ethics and Professional Review, the adjudicatory arm of NASW, and was also a member of the National Ethics Committee of NASW.   He helped with the drafts of the NASW Code of Ethics and was an author of the NASW Professional Standards.  He has extensive teaching experience, numerous committee assignments and is active on HMS’s Clinical Ethics and Organizational Ethics Consortiums as well as HMS’s Ethics Leadership Group.  Steve was involved with the Preventable Harm to Respect and Dignity initiative within health care at BIDMC as well as a member of BIDMC’s Emergency Management Team.  And as a member of the HMS Task Force on Disaster Preparedness, Steve was one of the authors of the Ethical Aspects of Emergency Preparedness which Massachusetts adopted during the COVID-19 pandemic.  He is the author/co-author of a number of articles, chapters, and a book entitled  Legal Issues in Social Work (2004).

Steve is an expert in Behavioral/Mental Health for the OpenNotes Program and started the first-ever program in making behavioral health therapist notes directly available to patients through their personal computers in 2014.   Steve also helped to create an interprofessional training program at HMS led by medical/nursing/pharmacy/nutrition and social work interns in providing direct outpatient primary care to complex care patients.  Steve is especially interested in how transparency can foster greater trust, as well as improved care, with all health care providers, especially including behavioral health.  

While Steve retired from his primary roles at BIDMC, he continues to work in the OpenNotes Program, teaches at both HMS and Simmons, and is a consultant for Massachusetts Medical Benevolent Society.  

Outside of work, Steve enjoys time with his family and friends.  He loves fishing, hiking, animal tracking, birding and following the Red Sox and other professional sports. 

Disclosure Statement: 

The instructor(s) for this course receive compensation for their services. There are no reported conflicts of interest to disclose. 

CE Hours

This course does not offer CE credits, just great content.

The same course is available for purchase and offers 1.5 CE hours for behavioral health clinicians. See "related products" below.

This course is a non-interactive, online self-study.

Participants may request a printed version of their certificate of completion to be delivered by mail. A shipping/handling fee of $6.95 will be charged per request. Shipping internationally may require an additional charge.

Accommodations and Policies

Close Captioning is available for live webinars and recorded video presentations.

You can click on the following links to view our policies:

• Accommodations for Individuals with Disabilities.
• Cancellation Policy
• Grievance Policy
• Support Options
• Disclosure Statement