Writing Progress Notes Robert W. Marrs, MS, LMFT On Behalf of Wisconsin Association for Marriage and Family Therapy
Writing Progress Notes The following slides are presented on behalf of Wisconsin Association for Marriage and Family Therapy and are intended to provide best practices in writing outpatient psychotherapy treatment notes. The information presented is based on the HIPAA Privacy Rule and Wisconsin laws and statutes regulating the practice of psychotherapy.
Writing Progress Notes Robert Marrs is a licensed marriage and family therapist and AAMFT approved clinical supervisor. He is past president of Wisconsin Association for Marriage and Family Therapy, and serves as the Manager of Clinical Services at Aurora Family Service in Milwaukee, Wisconsin.
Defining Psychotherapy Wisconsin Chapter 457.01 (8m) “Psychotherapy” means the diagnosis and treatment of mental, emotional, or behavioral disorders, conditions, or addictions through the application of methods derived from established psychological or systemic principles for the purpose of assisting people in modifying their behaviors, cognitions, emotions, and other personal characteristics, which may include the purpose of understanding unconscious processes or intrapersonal, interpersonal, or psychosocial dynamics.
Defining Marriage & Family Therapy Wisconsin Chapter 457.01 (5) “Marriage and family therapy” means applying psychotherapeutic and marital or family systems theories and techniques in the assessment, marital or family diagnosis, prevention, treatment or resolution of a cognitive, affective, behavioral, nervous or mental disorder of an individual, couple or family.
Common Definitional Elements: • Diagnosis & Assessment • Mental, emotional, cognitive, behavioral, systemic disorders • Addictive disorders • Mental health conditions • Personal characteristics • Treatment • Application of theories • Application of techniques • Outcome • Resolution or prevention of identified disorders / conditions • Modification of behaviors or personal characteristics These are the psychotherapeutic activities that should be documented in a session progress note.
The “Golden Chain” • Everything in the mental health record links together in what is referred to in healthcare as the “golden chain”. It includes the intake/assessment, the diagnosis, goals/objectives, service plan, DAP progress notes, and discharge plan. • The psychotherapy progress notes are a crucial link in the chain connecting the therapist’s work in treatment with the diagnosis and established treatment goals. • (HIPAA 45 CFR 164) Progress notes document the psychotherapy, or marital and family therapy being provided, and describe the patient’s progress toward identified outcomes. • It is considered best practice to complete and sign your progress notes within 24 hours of the therapy session.
Definition of a Progress Note • Progress notes must include the following: • Session start and stop times • Modalities and frequencies of treatment furnished • Results of clinical tests and assessments, and • Any summary of the following: • Diagnosis • Functional status • Symptoms • Prognosis, and • Progress to date • Signed and dated by the treating provider including the providers educational degree and credential
Definition of a Progress Note • In other words, your progress notes need to include: • Description of major events or topics discussed (D) • Specific interventions provided (D) • Observations and assessment of the patient’s status and functioning (A) • Including current Dx, risk status, and GAF score • Any plans for the future including (P): • Homework assigned • Recommendations • Additional resources • Alternative treatments One of the most common progress note formats is DAP: Data / Assessment / Plan
What is NOT in a Progress Note? • Therapist hypotheses • Therapist speculation • Therapist personal feelings or judgments about the patient • Any information, events, experiences, or descriptions not relevant to the patient’s functional status and treatment plan • Identifying information about persons who are not directly involved in the patient’s treatment • Clinical judgments, conclusions, impressions, or diagnoses that cannot be justified by accepted methods of assessment and treatment, therapist scope of practice, and other acceptable forms of clinical evidence.
Scope of Practice The basic intent of scope of practice is to ensure that a healthcare professional has the appropriate education, knowledge and experience to care for a patient. Scope of Practice is defined by the following: • State and Federal Law • Licensing / credentialing • Standards of care and professional conduct • Empirically tested or universally accepted theories and techniques
Scope of Practice • Consider the following factors when determining scope of practice: • Patient population (E.g., age, gender, socio-economic status, culture) • Cultural competency matters • Patient diagnosis • Identified patient system (E.g. individual, couple, family, group) • Therapeutic interventions and techniques • Methods of assessment
Progress Notes (Cont.) • Therapists should never write anything in a progress note that is not reflected in their scope of practice • Therapists should never write anything in a progress note that cannot be justified or validated by appropriate clinical evidence and investigation • Less is better! • Exception: • Situations involving increased risk of harm to self or others • Decisions regarding voluntary / involuntary discharge • Significant changes in functionality and/or level of care • Any other critical incident as defined by policies and procedures
Progress Notes: Additional Tips • Consider how the patient is represented • Avoid using words like “good” or “bad” or any other words that suggest moral judgments • Avoid using tentative language such as “may” or “seems” • Avoid using absolutes such as “always” and “never” • Write legibly • Use language common to the field of mental health and family therapy • Use language that is culturally sensitive • Use correct spelling / grammar – proofread your notes
Progress Notes: Additional Tips • Look for potential biases that may misrepresent the patient, or suggest boundary violations in the therapeutic relationship • Provide detailed information regarding any additional services or resources that are recommended for the patient as well as the patient’s response to these recommendations • Provide specific information regarding any additional assessment or test instruments used (E.g. Beck Depression Inventory), including the results of the test, their relationship to the treatment plan, and the patient’s response. Be sure you are qualified to administer such inventories
Progress Notes: Additional Tips • Below are the different types of progress notes written during the course of outpatient mental health treatment: • Initial Assessment / Admission Note – Written after the first therapy session in which you conducted a biopsychosocial assessment of the client system. This session should always be coded as “initial assessment (90801). • Individual Session – Written after every therapy session in which the client system was an individual (90806) • Couples/Family Therapy Session – Written after every therapy session in which the client system was a couple or family (90847) • Collateral Session – Written for therapy sessions when members of the client system are present without the client him/herself (90846) • Client Consultation – Written whenever you consult the case with a supervisor/consultant/ or other treatment provider (code it as non-face-to-face time) • Non-Billable – Written for any other event, activity, or communication that is not considered a “billable” service by industry standards.
Progress Notes–Initial Assessment • Admission Note – The therapist must write a progress note following the initial assessment session with the patient. This progress note, or admission note, should also include: • Presenting problem • Who participated in the session • Therapist observations • Acknowledgment of informed consent and patient rights discussions • Acknowledgment that a biopsychosocial assessment was performed • Acknowledge of any risk factors • Therapist recommendations
Progress Notes-Discharge • Discharge Note – The therapist must write a progress note following termination with the patient. This progress note, or discharge note, may correspond to the final session, or as part of the discharge summary. It should include the following: • Summary of treatment provided • Level of progress achieved according to the current treatment plan • Reason for termination • Recovery plan / recommendations
Psychotherapy Notes “Psychotherapy notes”means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the patient’s medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. 45 CFR 164.501.
Psychotherapy Notes The key elements of psychotherapy notes and its use are that psychotherapy notes: • Are produced by a mental health professional • Are separated from the rest of the medical record • Do not include the basic treatment and record-keeping that goes in a standard progress note, and • Are not open to disclosure to the client or anyone else Providers should not keep psychotherapy notes without the permission of their clinical supervisor and/or clinic administrator. If approved, the provider should maintain his/her psychotherapy notes in accordance with clinic policy and the HIPAA Privacy Rule.
Wisconsin Code of Conduct MPSW 20.02 – In the State of Wisconsin, professional misconduct includes: (18) Failing to maintain adequate records relating to services provided a client in the course of a professional relationship. A credential holder providing clinical services to a client shall maintain records documenting an assessment, a diagnosis, a treatment plan, progress notes, and a discharge summary. All clinical records shall be prepared in a timely fashion. Absent exceptional circumstances, clinical records shall be prepared not more than one week following client contact, and a discharge summary shall be prepared promptly following closure of the client’s case. Clinical records shall be maintained for at least 7 years after the last service provided, unless otherwise provided by federal law.
Relax… You are in a training program learning how to do this. We don’t expect your notes to be perfect, but we do expect that you do them and do them within the required timeframe. The quality of your notes will improve with time. Please know that we are always here to help you.
Please consult your clinic’s policies and procedures manual, and the Wisconsin Department of Health Services Bureau of Quality Assurance for best practices in mental health documentation