Share Notes

Odysseus

I was talking about this with a friend today and I just thought I would see if anyone here had any thoughts or experience on this this.

They have been talking about this in my service for a long time, [if it will ever happens I don't know] but the idea is just to have one file on the client rather than a medical, a therapeutic one etc.

Now as therapists we often deal with very senistive material, that clients will not speak to other professionals about, or they may just name the issue with other staff and articultate the issue more more with us.

Additionally we often deal with a psychical reality rather that the actual reality, transference with other staff, the list goes on. In other words these notes may not be suitable for other staff to read.

It also raises the question who are the notes for:
The organisation?
For supervision?
As memory aids?
For FOI reasons?
For Children frist reasons?

Should we write process notes or progress notes?

So anyone any thoughts on this?

The Black Oil

I suspect that this won't help in any way with your query, but I was at a talk that featured this system late last year and was rather impressed by how something like this could help in move the paper to the digital era re notekeeping/sharing, meetings, organisation, etc.

http://www.mhis.ie

Odysseus

The Black Oil wrote: »

I suspect that this won't help in any way with your query, but I was at a talk that featured this system late last year and was rather impressed by how something like this could help in move the paper to the digital era re notekeeping/sharing, meetings, organisation, etc.

http://www.mhis.ie

Yeah, interesting but not what I'm looking for at this time. I have never used it myself, as it is not used in any of the clinics I work in. However, my service uses the DAIS system, same type of thing I think, the whole team can write up their notes on it.

I just wonder what systems are used other, and if notes are shared with the team in some places, and hopw people work that.

The Black Oil

If you don't get an answer here, are there any mailing lists/discussion things you're on that you could contact?

Odysseus

The Black Oil wrote: »

If you don't get an answer here, are there any mailing lists/discussion things you're on that you could contact?

Cheers, no none that I would be aware of. Aware of any yourself?

sigmund.jung

Benefits for having different modalities having separate paper notes is that the GP/methadone prescriber can see a patient, update notes, see next patient. Previous patient can go immediately to counsellor without the notes having to be swapped out. If it was all online, concurrency would also be allowed for.

Purpose of notes are written record of consultation, for clinican to review prior to seeing patient, for new clinician to refer to when taking over patient care etc. etc.

Kooli

I wouldn't agree with shared notes, but I would strongly agree with consultation and case conferences between different professions.

Thinking of myself as a client, why would I be OK with my GP having access to the conversations I had with my therapist?? Why would I want my therapist having access to confidential medical information about me?

Confidentiality is the cornerstone of therapy. Without it, it doesn't work.

Odysseus

Kooli wrote: »

I wouldn't agree with shared notes, but I would strongly agree with consultation and case conferences between different professions.

Thinking of myself as a client, why would I be OK with my GP having access to the conversations I had with my therapist?? Why would I want my therapist having access to confidential medical information about me?

Confidentiality is the cornerstone of therapy. Without it, it doesn't work.

Within the M-D-Team it is often argued that confidentially is between the team not client and staff member.

Not other staff may be aware of issues such as experiencing sexual violence when younger; but I would expect that the therapist would possess much now subjective information on the matter; to give one example.

I'm also thinking of the client discussing a negative transference with another staff member and that staff member reading it and not understanding the concept. Additionally what if I am taking notes of a dream or fantasy?

Also there is some much subjective material expressed as a person works through their own position on life, morality etc.

This raises the question of what we record in notes, do we avoid all the subjective [highly personal] material and just focus instead on progress rather than process to avoid this?

sigmund.jung

I presumed Odysseus was talking about a multimodal facility, i.e GPs, counsellors and therapists working in the same building for the same patients. There, sharing of notes, seems reasonable. As opposed to you seeing a therapist privately only for her to send her notes to her GP.

If you are a client / patient / service user and use a GP and a therapist in the same facility but don't want them discussing your case / sharing information I don't think you'd get a good service but i suppose you're entitled to request that.

Odysseus

sigmund.jung wrote: »

I presumed Odysseus was talking about a multimodal facility, i.e GPs, counsellors and therapists working in the same building for the same patients. There, sharing of notes, seems reasonable. As opposed to you seeing a therapist privately only for her to send her notes to her GP.

If you are a client / patient / service user and use a GP and a therapist in the same facility but don't want them discussing your case / sharing information I don't think you'd get a good service but i suppose you're entitled to request that.

That's the situation here that I am refering to. A m/d team GP, Nurse, Counsellor, would be the only team members that would have access to the notes, there would be other team members but the would not have access to the case notes if this went ahead.

However, you seem to be suggesting that the GP and nurse seeing my notes would be benefical to the client? I would agree with that.

Why would you think that the client would access a better service if such access was to happen.