Psychiatric Annals

Editorial Free

OpenNotes: Implications for Psychiatry

Andrew A. Nierenberg, MD

If you have not yet heard of OpenNotes, you may not be aware of a movement to have patients have access to their medical notes including in psychiatry.1 Many patients have welcomed OpenNotes as yet another step in the evolution of the patient-doctor relationship with more openness and transparency. Many doctors have also welcomed this advance, although others have some reservations. Those doctors who welcome OpenNotes believe that it will help with communication, will allow patients to have access to information that they can use for not only understanding their maladies better, but can also help them collaborate with their doctors regarding treatment and achieve better outcomes. Those doctors who have reservations believe that if patients see what doctors have written about them, then patients will become upset or object to the observations and conclusions in the notes. How will patients react if they have hallucinations or delusions with little insight and then read the notes stating that they are psychotic? Will this anger patients and cause a rupture in a therapeutic relationship?

Overall, we should weigh the evidence for benefits and risks (just as we do for any intervention) of OpenNotes. Benefits include improved shared decision-making, access to information that patients usually forget after their visit (including instructions about how to take medications), and greater patient autonomy; by the way, doctors frequently think that they have communicated clearly with patients, but the evidence suggests that doctors tend to overestimate how much patients actually remember.2 Risks include patients having access to information that the doctor believes may not be therapeutic (instead, that information is meant to help guide the doctor's decisions), and as stated earlier, observations and conclusions that could be upsetting.

OpenNotes also provides us with the opportunity to rethink the purpose of the hallowed (and mandated) tradition of writing notes. Secret notes, acronyms, and specialized guild language of medicine can be viewed as methods to maintain power and hierarchy. If we know patients will be reading our notes, then not only are they no longer secret, but we need to be mindful of our audience and minimize acronyms (I must admit that after reading thousands of papers and grants, I have developed “acronymophobia,” especially for TLAs - three letter acronyms). We also need to shift to thinking about how we might write our notes in a way that would be therapeutic even if our notes contained inconvenient truths.


  1. Blease CR, O'Neill S, Walker J, Hagglund M, Torous J. Sharing notes with mental health patients: balancing risks with respect. Lancet Psychiatry. 2020;7(11):924–925. doi:10.1016/S2215-0366(20)30032-8 [CrossRef] PMID:32059796
  2. Sandberg EH, Sharma R, Sandberg WS. Deficits in retention for verbally presented medical information. Anesthesiology. 2012;117(4):772–779. doi:10.1097/ALN.0b013e31826a4b02 [CrossRef] PMID:22902965

Andrew A. Nierenberg, MD

Andrew A. Nierenberg, MD, is the Thomas P. Hackett, MD, Endowed Chair in Psychiatry, the Director, Bipolar Clinic and Research Program, and the Director, Training and Education, MGH Research Institute, Massachusetts General Hospital; and a Professor of Psychiatry, Harvard Medical School.

Address correspondence to Andrew A. Nierenberg, MD, via email:


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