Category Archives: Clinical Documentation

Theoretically Based Concepts in Documentation

person-apple-laptop-notebookI’m using a psychodynamic theoretical orientation in my work with clients, and I don’t know how much explanation of these concepts to put in my client’s progress notes and assessment. If anyone else looked at my notes, they might not understand why I chose particular interventions without the theoretical background. However, I learned from my supervisor that documentation should be behavioral rather than psychodynamic.

This is an important issue to consider in creating a client record, since your record may be viewed by other professionals or by your client. The primary interest for others viewing the client’s record is less about the reason for your interventions and more about what you did and how your client responded. When a client or another professional requests a record, it is most often for the purpose of insuring continuity of care or to learn about your client’s presenting problem and progress. You can maximize the value of the record for those purposes when you use language that is easily understood by people who are unfamiliar with psychodynamic or other theories of psychopathology and psychotherapy. It is likely to be distracting rather than helpful to try to explain the theoretical basis for your interventions.

One way to create a record that others can understand and use is to translate theoretically based concepts into terms that are more descriptive and objective. An example is to describe the client as “protecting herself from painful experiences” rather than “using the defense of projection” or to describe your intervention as “assisting the client to develop insight in order to modify his habitual patterns” rather than “interpreting unconscious motivations for self-sabotage.” This approach may be contradictory to assignments in your academic courses, where you are being evaluated on your understanding of and ability to apply theoretical concepts. That is an important skill, and it is a crucial element to an effective treatment plan. However, clinical documentation serves a different purpose and is written for a different audience than academic papers or a clinically oriented theoretical formulation of a case.

Another way to focus your attention in writing clinical documents is to keep the client’s goals uppermost in your mind. This means being aware of the context of your interventions as working to help the client make the changes they want to make. This might lead you to say “declined client’s request to extend the length of the session and supported her ability to self-regulate intense emotions” rather than “set limit on client’s attempt to test boundaries when in a dysregulated state.” Your documentation will convey a more collaborative tone when you focus on the desired outcome of your interventions, which is preferable when the record is viewed by others including the client.

I hope you can use some of these suggestions in writing clinical documentation that is understandable to professionals who have a different theoretical perspective and to nonprofessionals. Please email me with comments, questions, or suggestions for future blog topics.

Updating Client Documentation

imgresI have seen a client for three months and have learned new information that changes my diagnosis from major depressive disorder to post traumatic stress disorder. In light of this new information, we’re also working on different treatment goals than we talked about at the beginning. What is the best way to document these changes in our work together?

You are describing a situation that is common in clinical work. The information that clients give us at the beginning of treatment reflects what is uppermost in their minds as well as what they feel safe to disclose. Often they remember and reveal more after they feel understood and become less worried about being judged or criticized. When you work with children or adolescents, you may also get additional information from parents or teachers that affects your diagnosis and treatment plan.

Before discussing how to document these types of changes, I’ll share some thoughts about the content of your documentation. Since your new diagnosis is post traumatic stress disorder, your client has evidently told you about past traumatic events as well as revealing more about the different symptoms she is experiencing. The details of these traumatic events may be sensitive, and you should think about the possibility of your client or a third party viewing your record as you record this information. Your documentation should include enough detail to support and explain your clinical decisions while also preserving your client’s privacy. For example, you could say that the client was exposed to domestic violence but put the details of the incident and the family situation in your psychotherapy notes rather than the clinical record. (Click here for an explanation of the difference between progress notes and psychotherapy notes.)

Your documentation of these changes in your clinical work can take two forms: progress notes and separate assessment and treatment planning documents. Ideally, the changes would be reflected in both of these documents. If your agency receives a request for the client’s record, they may only send the assessment documents and not include progress notes. However, your progress notes should describe the treatment progress, and this requires including the information you describe above.

Regarding the progress notes, they should incorporate your client’s report of symptoms and traumatic incidents and your revision of the diagnosis. If you only included the client’s report in your previous notes, you can add a paragraph to your next note identifying the new diagnosis and your assessment that led to this revision. Similarly, you should describe your conversation with the client about new treatment goals and your plan for working on them. It is best for this to be included in the note for the session in which you had that conversation, but if you have already written that note you can create a supplemental note or include the information in a note for a later session, identifying the date of the original conversation.

If your agency has one or more documents for assessment and treatment planning, you may have a form for revisions or updates that you are required to complete every three, six or twelve months. If you don’t have a version of those forms to use for revisions, check with your agency supervisor. You may be able to write an addendum to the original form or simply complete a new assessment and treatment plan with a new date.

I hope you found this helpful in updating client documentation. Please email me with comments, questions or suggestions for future blog topics.

Documentation in Private Practice

man-taking-notesI’m going to be leaving my agency internship for a private practice internship. What are the differences in requirements for writing progress notes in a private practice compared to an agency?

The requirements for documenting your client sessions are not specific to the setting, but agencies often follow guidelines set by third party funders. These guidelines may not be applicable to your private practice internship if you are not billing a third party insurer.

Before directly addressing the specific requirements of documenting sessions with progress notes, I’ll review the reasons for keeping progress notes when your client is paying directly for treatment. Under the Health Insurance Portability and Accountability Act (HIPAA), each client is entitled to receive a copy of her/his treatment record on request and you are obligated to provide one if requested.

Client records might also be requested, with the client’s permission, by another health care provider, by an administrative organization evaluating your client’s application for assistance (for example, Social Security Disability Income), or by an attorney in a lawsuit brought by your client claiming damages for emotional distress. A client record would also be required if you need to respond to a complaint or lawsuit filed by a client against you. You may believe that all of these situations are unlikely to occur with your private practice clients, but being without an adequate record could place you at some degree of risk or could create a complication for your client. You might not release the full record in some of these situations, but you would need a record in order to respond to the request.

Let’s return now to the issue of requirements for progress notes. All aspects of the treatment you provide are measured against the professional standard of care. The standard of care is the generally accepted practice used by other professionals providing a similar service. The codes of ethics of the professional associations for psychologists, marriage and family therapists, and social workers state that clinicians should keep accurate records documenting their work, without specifying the content of those records. Therefore, keeping progress notes for psychotherapy sessions is the standard of care.

There are several methods you can use to guide you in writing progress notes in a private practice setting. First, I would suggest asking your supervisor for her/his standards for the format and content of progress notes. If your supervisor doesn’t have a specific format, you could adapt the format you used at your agency internship to fit your private practice. You can also check with colleagues and your local or state professional association for templates used by other therapists.

Two resources you can check in print or online are the American Psychological Association Record Keeping Guidelines and a book by Donald Wiger entitled “The Psychotherapy Documentation Primer” published by John Wiley & Sons in 2012. These resources contain a list of the information that should be included in a progress note for each service provided. To summarize, the most important elements to include in a progress note for a psychotherapy session are: the context of the session (date, time, length, who attended, location, service provided), status of the client’s symptoms and functioning, any assessment you conducted and the actions taken as a result of the assessment, interventions provided, plan for future treatment, and your signature including your licensure status and date signed. You probably also need to include some narrative description of the topics covered in the session.

One additional issue to keep in mind is that HIPAA defines psychotherapy notes as distinct from progress notes. Psychotherapy notes are kept by you for your own analysis and may contain conjecture, inference, judgments and emotionally charged material. Psychotherapy notes are not part of the official treatment record and do not have to be released to the client or other parties. Progress notes should be factual and objective in describing your observations and interventions without the more subjective material that can be kept in a psychotherapy note.

I hope you found this information helpful in writing progress notes in a private practice internship. Please email me with comments, questions or suggestions for future blog topics.

Writing Progress Notes

man-taking-notesI am in a new practicum placement and this is my first experience with writing a progress note after each session.  So far it takes me almost an hour to write each note, since I want to write down
everything that happened in the session.  How can I write notes in a shorter time and how do I decide what to leave out? 

This is a common dilemma for new trainees and it is important to develop facility with writing concise progress notes that include only the details that are appropriate for the client’s record.  At your stage of training, it is probably realistic to work toward writing a progress note in 15-20 minutes. Allowing time for this within 24 hours of your session is important in order to not fall behind and develop a backlog of incomplete or unwritten notes.

Let’s look first at the purpose of a progress note.  Progress notes are part of the client’s treatment record and may be viewed by the client and other third parties who are not clinicians.  Therefore, they should be relatively objective and descriptive without conjecture or emotionally charged judgments.  You should also avoid including details of the client’s current life and history that are emotionally sensitive and could bring psychological harm or shame to the client if they were revealed to a third party.  You do need to include enough detail about the client’s symptoms, therapeutic interventions and client’s progress to provide an accurate picture of the client and the treatment.

You will probably find it helpful to keep notes on the details of the client’s life and history, suggestions and guidance from supervision or consultation, a detailed description of the therapeutic interactions (sometimes called a process note), questions or hypotheses, and your emotional countertransference responses.  These are defined as psychotherapy notes which you keep for your own understanding rather than being part of the client’s record.  I recommend keeping psychotherapy notes in a separate file, using client initials or a random number in place of identifying information such as the client’s name or date of birth on these notes, and shredding these notes when you no longer need them.

Your agency probably has a specific format for the structure and content of a progress note.  In addition to the body of the note which describes the session, you need to provide information about the type of service you provided (individual or family therapy, group therapy, case management, home visit, collateral parent session); the date, time and length of the session; who attended; location of the session; and your hand or electronic signature including your degree and licensure status or title.  In some cases, your supervisor’s signature may be required as well.

The body of each progress note is a report on the status of the client’s symptoms and functioning and the progress in treatment.  It should include both the client’s report and your observations of her/his symptoms and current functioning, a description of your interventions and the client’s response, your assessment of areas of crisis or danger, the client’s general progress toward the treatment goals, and your plan for continued treatment or changes in the treatment plan.  It is helpful to include general information about the content or topics you talked about, with a phrase like “client discussed conflict with her partner about financial issues” or “client reported having contact with her mother which brought up painful feelings of rejection.”  A guide for the appropriate level of detail is that a progress note for a session lasting 45-60 minutes should generally be a half-page to a full page unless the client is in crisis or at risk, which requires documentation of your assessment and plan for safety and may extend into a second page.

I hope you are able to use these tips to write progress notes more easily and quickly.  Please email me with comments, questions or suggestions for future blog topics.

Electronic Communication

therapyOne of the clients at my field placement has been using email to reschedule appointments and let me know about things she wants to talk about in our next session. This has been fine with me since it’s easier for me to read and answer a quick email than a phone message. However, her emails are getting longer and I don’t want to take the time to read and respond to them between sessions. How can I let her know this without causing a rupture in our relationship?

This is a good example of how communication in the therapeutic relationship can move quickly from simple and straightforward to complex and entangled. This can happen with conventional communication in person and by phone, but there are many more possibilities for complexity with electronic communication.

When communicating with clients by email, you need to be aware of security and privacy as well as clinical issues. Regarding security and privacy, email is not considered a secure form of communication under HIPAA, so you need to inform the client of the risk to her privacy for anything she sends you by email. In the future, you can include this discussion early in treatment, but you now have an opportunity to do so in response to the client’s expansion of her email communication with you. I recommend documenting your conversation about email security in a progress note so it is clear you have informed the client of the risk to her privacy and that she is making an informed choice to communicate by email.

There are also clinical issues related to email communication with clients, as you have found. Email is best used only for scheduling appointments. Some clients may also send information to you that is related to their treatment, in order to talk about it in the next session. Examples are a client forwarding an email from a family member or partner with whom she is in conflict, a parent forwarding information from a teacher about your child client, or a client wanting to tell you about something that happened or an insight she had during the week. It is safest to either let the client know you won’t respond directly to emails containing clinical information or to limit your response to these email to a simple acknowledgement and invitation to talk more in person in the next session. I recommend printing email exchanges with the client that contain clinical information and including them in the client’s record. Check with your supervisor about the policy at your field placement site.

At this point, you need to talk with your client about both security and clinical issues related to email. The conversation is likely to be less disruptive to the relationship if you begin by acknowledging your oversight in not talking about this sooner. You should let the client know about the risk to her privacy with email communication and ask if she wants to continue using email despite the risk. You can then move to a discussion of your preferences about the issues discussed by email, preferably by again acknowledging your oversight in not discussing it sooner. A straightforward description of the limits of email would be “I prefer to use email only for scheduling purposes and to save our discussion of other issues for when we meet in person. If there is something you want to let me know about, you can certainly send me that to me by email but I will wait to comment on it until we see each other.” You then can invite the client’s thoughts and reactions, again acknowledging that this is a change on your part if the client expresses confusion or worry about having done something wrong. This will relieve you of the burden of responding between sessions and will redirect the client’s communication to your sessions where you can talk about the issues in depth.

I hope you found this helpful in dealing with electronic communication. Please email me with comments, questions or suggestions for future blog topics.

Client Requests for Records

therapyI had a session today in which a client asked to see the notes I have taken that are part of her chart.  I told her I’d have to talk to my supervisor because I’ve never had a client ask for this before.  What choices do I have in deciding whether to give her the notes or not?

This issue was addressed by HIPAA, which created a national standard for client’s access to all medical records including records of psychotherapy.  Under HIPAA, the record belongs to the client and s/he has a right to request and receive a copy.  Exceptions are only made for instances where viewing the record would cause serious harm to the client and, in the case of child records requested by parents, harm to the psychotherapy relationship.  Most behavioral health agencies ask clients to make a written request and then provide a copy of the records within 1-3 weeks.

While HIPAA addresses client access to records from an administrative perspective, it doesn’t address the clinical issues that are often present when a client requests a copy of the current treatment record.  Your supervisor can be helpful in talking through the meaning and motivation for your client bringing this up with you.  Some factors to consider are the client’s previous experiences of secrecy and betrayal, issues of control and helplessness, interpersonal suspiciousness, and involvement in a legal case or application for disability.  Your client is more likely to tell you about the reasons she wants to see your notes if you make it clear first that you plan to honor her request.  In your next session, you can say “You told me last week you wanted to see the notes I have written for your chart.  I have the written request here for you to fill out, and I also am interested in what led you to ask for the notes.”  You can explore this further, if the client is willing to do so, by asking what she expects to see in the notes and how she feels about looking at them.

Most clinicians, especially those in field placement or practicum training, feel anxiety when a client requests the record.  You may anticipate, correctly or incorrectly, that the client will be upset or offended by things you have written in progress notes or the assessment.  Your assessment may include a diagnosis and case formulation that you haven’t explicitly shared with the client.  Your notes may accurately reflect some of the client’s obstacles to improvement and progress.  It is usually helpful to look at the record and to have your supervisor review it to identify anything that could be problematic.  Whether or not you anticipate a negative reaction from the client, it is usually wise to say “There may be portions of this record that spark questions or upsetting feelings for you.  I’d like to talk with you about anything that comes up after you’ve read it.”  Then you should follow up with a discussion in the following session about what it was like for her to look at her record.  If she has questions or was distressed by anything you wrote, I recommend being straightforward in your explanation.  If you regret anything you wrote, you can acknowledge that you wish you had used different wording or had described the situation differently.  In addition to negative feelings, she may feel pleased with her self-assertion and have an increased sense of empowerment when you respond to her request in a respectful, professional manner.

I hope you find this helpful in handling client requests for records.  Please email me with comments, questions or suggestions for future blog topics.

Beginning Behavioral Health Treatment

sunrise_1My agency has a lot of forms for clients to fill out at the first session. I want to build rapport in the first session but instead I’m explaining forms and getting the client to sign them. Are these forms really necessary?

Many clinicians feel frustrated about the amount of paperwork that is required when providing behavioral health services, especially in agency settings. Generally, each form meets a particular requirement and it may be helpful for you to ask your supervisor about the purpose and rationale for them if that hasn’t been explained to you. The two most important forms that are required by the legal and ethical standards of our profession are informed consent and notice of privacy practices. These establish a treatment relationship between you and the client. An informed consent form provides confirmation that the client knows the nature of the treatment, including its limitations, and agrees to participate. A notice of privacy practices informs the client about the exchange of information about the treatment between you and others, with or without the client’s permission. In California and some other states, clients must also be informed when the clinician is not licensed and is working under supervision. In addition to these basic requirements, your agency may have forms related to accreditation or certification, billing and payment, and collection of demographic and clinical data.

We often make an assumption that getting the client’s signature on required forms is an administrative task separate from the clinical work you are being trained to do. However, building rapport begins in your first interaction with the client and the way you discuss the forms and their content sets the tone for your future treatment relationship. You can convey your desire to work collaboratively with the client by introducing the forms with a statement like “I need to go over some aspects of our working relationship so that we have the same understanding of how we’ll be working together.” It is useful to practice summarizing the key points of each form so you can explain it concisely and clearly to the client.

One other tip regarding forms is to acknowledge the necessity to attend to some paperwork and express your interest in the client’s concerns. It is a good idea to prepare the client ahead of time when you set up the first appointment. At the beginning of the session, you can introduce the forms with a statement like “I’m interested in learning more about you and the concerns you have.” You can follow that with a collaborative statement like the one above or “Can we take a few minutes first to talk about some of the important points about our work together?” or “There are some things that I want to talk with you about before we begin.” You don’t have a treatment relationship with the client until the informed consent and privacy practices are explained and agreed upon, so it is imperative that you discuss these and ask for the client’s signature before moving into clinical material.

I hope you have a better understanding of the reason for the abundance of forms and can make use of these suggestions to handle them in a sound clinical manner. Please email me with comments, questions or suggestions for future blog topics.