A recent question on the CFHA listserv struck a nerve with me and other CFHA members. A team leader described a familiar dilemma: their behavioral health department keeps clinical notes “behind the glass” in their electronic health record (EHR), meaning anyone outside the department has to enter a password and trigger a notification just to read them. The rest of the primary care team, the PCPs, nurses, medical assistants, and care coordinators, may not be able to see behavioral health notes without jumping through that hoop. The team was asking whether that restriction makes sense in integrated primary care.

I will argue that it doesn’t make sense. But understanding why requires us to look at what integrated care actually is and what message our documentation practices send to the people we work alongside.

Start with a basic distinction. Under HIPAA, psychotherapy notes are a provider’s personal notes kept separate from the medical record (U.S. Department of Health and Human Services [HHS], 2025). Progress notes are different, they document services delivered and clinical impressions relevant to ongoing care (Reiter, 2023), and they are part of the medical record subject to standard team access. The department of health and human services (HHS, 2018) also specifically notes that sharing protected health information (PHI) about patients with mental illnesses with other providers treating the same patient is allowed. Behavioral health providers in primary care write progress notes. These are clinical documentation, not private therapeutic journals, and should be treated accordingly.

The federal Agency for Healthcare Research and Quality (AHRQ, 2025) Lexicon for Behavioral Health and Primary Care Integration calls for the “Use of an explicit, unified, care plan in a shared record” and that “Implementing a care plan means all involved providers read and work from the care plan; these are shared care plans with ongoing communication among team members.” Placing behavioral health notes behind additional security barriers moves a practice in the opposite direction. It reinforces the idea that behavioral health is something separate, sensitive in a way that physical health is not. The whole point of integrated care is that behavioral health is part of health, not a separate service that medical patients also happen to receive.

As Dr. Reiter noted on the same listserv thread, the medical side of the record already contains plenty of sensitive information nobody puts behind a glass. Conditions and situations such as STI diagnoses and treatment, HIV status, reproductive health decisions, domestic violence screenings, genetic testing results, sexual dysfunction, terminal diagnoses and end of life conversations are already in the record. We trust the care team with all of that. If we are comfortable giving staff open access to those records, the argument that behavioral health notes need extra protection breaks down quickly.

It’s important to consider that when we talk about “other staff” accessing behavioral health notes, we are often really talking about practice managers, nurses, medical assistants, and care coordinators. These staff provide care and coordination to our patients every day. They need the whole clinical picture to do that work. Walling off behavioral health notes sends a clear message: this is not your concern. That is the opposite of what we want in an integrated setting.

The real safeguard is not a password prompt. It is thoughtful documentation. We have a professional responsibility to document only what is clinically relevant to the treatment team (Robinson & Reiter, 2016). A progress note should include the presenting concern, the functional impact, the intervention delivered, the patient’s response, and the follow-up plan. It should not include detailed trauma narratives, verbatim session content, or information the patient shared with the expectation that it would stay between them and their provider. If you would not want the whole team reading it, it does not belong in a progress note. Common recommendations for progress note documentation relevant to this discussion are noted in Table 1 (Cameron et al., 2002; Reiter, 2023).

Integrated care works when every member of the team operates from the same information. Breaking the glass to read a teammate’s note is not integration, rather its continued presence is a reminder that while integrated care is a much more common practice (Jabbarpour et al., 2022), we haven’t fully realized our goals.