One of the questions I receive the most as a consultant and clinical supervisor is how to determine what clinical documentation is required. Many therapists struggle to determine what needs to be documented in a medical record compared to the notes they keep on someone receiving services (often called “psychotherapy notes,” “private notes,” or another related term). I am going to use the terms “medical record,” “treatment record,” and “clinical record” interchangeably for your official treatment record. This is the clinical documentation that is released when someone requests copies of your records, when you are subpoenaed, or when a client requests a copy of their treatment notes (intake assessment, progress summaries, treatment plans, record of communication with the client and others related to their treatment, discharge notes, etc.). For those of you who bill insurance, you are already keeping a clinical record to submit your insurance claims and this post will guide you to keep more effective notes.
If you’re taking a lot of time on your notes, hopefully this overview will help you uncomplicate it so you can reduce time spent on administrative tasks. Practitioners who only see private-paying clients are often less accustomed to keeping separate records, as you do not document for insurance reimbursement. I highly recommend keeping separate clinical and private psychotherapy notes to avoid having to release your detailed notes and case conceptualization upon a records request. For those who are new to the field or new to learning effective clinical documentation skills, I recommend using a platform that offers templates for your intake, progress summaries, and discharge summaries. Using such a system may also automate the process of keeping a separate, official record from your private psychotherapy notes. Many also streamline billing for private paying clients as well as insurance reimbursement, which is an added bonus of paying for these systems. Most come with a monthly or annual subscription and often offer a limited free trial.
If you work for a non-profit that does not bill insurance, feel free to reach out to me with general questions about documentation practices. The requirements for your notes may differ from those governed by HIPAA, and it’s important to ensure they align with any grants your agency has received. You’ll also want to be thoughtful about the type of information you include in those records.
Official Treatment Record
At the most basic level, the treatment record needs to demonstrate medical necessity for insurance reimbursement and in case of audit. When in doubt, I recommend asking yourself, “Does this person’s insurance company need this information?” Typically, the details of what is bringing someone into therapy (e.g. The details of their trauma; the details of their most recent fight with their spouse; their most private thoughts) do not need to be included. You should always write these notes keeping the client in mind, as they can request copies of their record at any time. Are you using the correct pronouns throughout your session notes and throughout the clinical record? Are you using objective language (e.g. person was slurring their words and reported drinking alcohol prior to session) or subjective or even biased language (e.g. person was drunk in session)? When objectively documenting someone’s observable behavior, it should relate to established treatment goals and/or your case conceptualization. Additionally, I don’t recommend documenting something in the record that you have not addressed with your client (e.g. If you did not address their slurred words or your suspicion that they may have used something prior to session, it is not relevant to your treatment with them in this session).
Golden Thread
If you bill insurance, and particularly if you bill Medicaid, then you should be familiar with the “Golden Thread.” Your whole record needs to demonstrate that there is a purpose to the services you are rendering when billing insurance, which means that all of your clinical documentation connects through the “golden thread” of clinical assessment and medical necessity. Someone’s presenting problem relates to their diagnosis, which relates to their treatment goals, and the treatment goals and interventions are incorporated into each progress summary.
Your documentation consists of the following, which all carries through the Golden Thread:
- Assessment (likely your clinical intake assessment)
- Diagnosis (this is supported by your assessment)
- Treatment plan (including diagnosis/associated problems, goals, objectives (SMART goals), plan for intervention w/ frequency of appointments)
- Progress summaries (demonstrating the work you are doing to resolve the identified problems your patient is experiencing)
- Discharge summary and plan (should indicate whether services are being terminated due to disengagement, meeting treatment goals, etc. and any referral or follow-up plans discussed during your final appointment)
Treatment plans are updated regularly (Medicare and Medicaid require that these are updated every 3 months, but commercial insurance and private paying clients will have different or no requirements). This is a clinical and collaborative process and reviewing progress and soliciting client feedback on a regular basis is best practice. I recommend discussing a plan for evaluating progress with clients during the first intake session.
Progress Summaries
The bulk of your clinical documentation and official treatment record is comprised of progress summaries, which you write after each session or other billable service or outreach. Your progress summaries can be quick and concise; a few sentences in each section that demonstrate the gist and necessity are sufficient.
- Diagnosis
- Start and end time of session
- Billing code
- Location of session (or where the person receiving services is at the time of your telehealth session and that the appointment occurred over video or telephone)
- Progress summary: The most common note types are SOAP (Subjective, Objective, Assessment, Plan) and DAP (Data, Assessment, Plan) notes. I actually prefer the BIRP (Behavior, Intervention, Response, Plan) note and will review that below:
- Behavior: Objective indication of behavior in session (can be an MSE) as well as self reported progress and intention of today’s session. Being objective is key for this section: This is observable in session and you might use quotes for self-reported information about progress and session focus.
- Intervention: What modality did you (primarily) utilize to support the person in this therapy session? Use the language of the modality in your note to demonstrate how you used it effectively to address the symptoms you identified. The use of the intervention should relate to your treatment plan, which should have specific goals and objectives that are relevant to how this person’s diagnosis impacts their ability to navigate the world and their level of distress. The behaviors you’ve identified in the first section should directly relate to your use of intervention in session.
- Response (and strengths): What strengths does this person demonstrate? Is the individual aligned with your approach? Are you noticing discord in your therapy sessions? Are you noticing a change in behavior and/or level of distress that indicates your approach is supporting the person you’re treating?
- Plan: What are the next steps you and the person in your care taking? At the very least, this should indicate your next session, but ideally it will also include any contact you’re planning to have with other providers, skills the individual might practice between sessions, and if you discussed a plan for the next session, it should include that, as well.
When you have a crisis contact, identify suicidal ideation, or make a mandatory report, your documentation should be more detailed than usual. If confidentiality is broken for a mandatory report, you’ll need to include sufficient detail that substantiates the need to make the report. When there is crisis or you’ve assessed for suicidal or homicidal ideation, a detailed assessment should be included that sufficiently explains why you did or did not take additional action. If you completed a safety plan and/or discussed means restriction, those details should also be included. The person’s response to your assessment and plan should be documented.
Psychotherapy notes
These notes are going to be significantly more detailed than your clinical documentation in the treatment record. What you decide to include is subjective based on your practice, but this clinical documentation need to be kept separately to minimize your risk of needing to release them with your treatment record when requested or when subpoenaed. If you are keeping all of your notes by hand or on your computer, these notes should be in a separate computer file or written file that is separate from your official treatment record to protect yourself, the people you serve, and your notes. If your notes are not separated, then every note you have on a client is part of their official treatment record. Consult an attorney who specializes in HIPAA compliance for more guidance on storing your notes, releasing records, and especially in the event that you receive a subpoena.