Clinical Documentation

Kerry L. Holland, PhD, HSP

East Tennessee State University

Objectives

• Participants will apply various requirements for documentation unique to their practice. • Participants will develop a strategy for complying with those requirements in an efficient manner that best fits the needs of their practice. 

APA Record Keeping Guidelines

• Expire in 2017

Requirements of Regulating Bodies

• TCA• BOE•HIPAA (OCR)• Insurance companies/Medicare• Employers

For small or solo practice

• Resource: Edward Zuckerman, Paper Office offers wealth of information

Determining Your Needs or Requirements

•Medical record is not just a progress note, can include financial records, emails, voice mails, etc. • Paper or electronic?• APA Communities, electronic version developed by Jeff Younggren, et al to address needs of each state

Do your requirements differ depending on the patient population you serve?

• Record retention will be impacted•What constitutes progress note•What constitutes medical record• Treatment plan requirements, etc.

Look to insurers, licensing or regulatory boards for guidance

• Licensed mental health agency requires treatment plan within 30 days of admission• Progress notes require reference to treatment plan, progress made, risk assessment, compliance, mental status, etc.

Why Document?

• Risk management• To know where you are with clients• So that other professionals can know where you are with clients…•Other reasons?

What to document?

• Patient Progress • Financial agreements• Financial records• Voicemails, phone conversations• Emails• Supervision

• Consultations with other professionals• Correspondence with patient• Treatment plans•Outcome measures• “Non-clinical” data

Bloom’s Taxonomy for Documentation (almost verbatim, APAIT, 2009) With apologies to Harris & Younggren

Evaluation

Synthesis

Analysis

Application

Comprehension

Knowledge

Knowledge

• You know you have to keep records• You know there are ethical, legal & insurance rules about form & content but do not know the details• Your record keeping practice is driven by insurance requirements and professional standards

Comprehension

• You understand the APA record keeping guidelines, laws and regulations of the state and that certain information is required to be maintained• You have a method of record keeping that you learned during your training, which you have modified slightly based on your experience and education• You think of record keeping as an unpleasant administrative task. It has a low priority in your work.

Application

• You have developed a system of record keeping which works for you following a template, the content of which you follow religiously• You know that bad records can create risks. You know that records can be important as a way of reminding you about what is happening in the treatment• You are also aware of record keeping requirements of insurance companies and use their formats• You understand HIPAA and keep psychotherapy notes separate from your regular record

Analysis

• You have developed a system of record keeping that is able to provide you with assistance in conceptualizing the work you do and improve its quality• You have a risk management strategy in which record keeping is

an important element• You understand that there are no clear directives about record

keeping content, but you have a good sense of what content is important to you, to your relationship with your client, to anyone who will be evaluating your competence & professional judgment• You understand & integrate consultation into the process of

record keeping

Synthesis

• Your record keeping becomes an integral part of professional work you do. It is a way of cognitively understanding the issues presented by a particular patient; reviewing & refining your strategy in treating that patient• You have developed a method that helps you to budget your time

for record keeping• You understand that perfect is the enemy of the good• You know that it is the totality of your record that is important,

not each specific sentence or fact• You manage your high risk patients so that you are able most of

the time to keep records cost effectively

Evaluation

• You develop tx plans and progress notes without much thought or anxiety. You review what you’ve written critically on a regular basis. You understand their value & limitations they impose on you. You adapt when demands of your practice require you spend less time in documentation.• You use your records to help your patients confront issues which may be difficult & see them as a way of fostering & enhancing the tx relationship• You know that you can confidently take risks with difficult patients because your records will show that you are prudent, competent and thoughtful about what you include in your records

Medicare Standard Often Adopted

• Pull a note from anywhere in the chart and know what is the diagnosis, treatment plan, progress, compliance, risk assessment, etc.

Demo template with macro