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Writing Progress Notes

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1 Writing Progress Notes
Robert W. Marrs, MS, LMFT On Behalf of Wisconsin Association for Marriage and Family Therapy 5/7/2012

2 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. 5/7/2012

3 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. 5/7/2012

4 Defining Psychotherapy
Wisconsin Chapter (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. 5/7/2012

5 Defining Marriage & Family Therapy
Wisconsin Chapter (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. 5/7/2012

6 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. 5/7/2012

7 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. 5/7/2012

8 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 5/7/2012

9 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 5/7/2012

10 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. 5/7/2012

11 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 5/7/2012

12 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 5/7/2012

13 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 5/7/2012

14 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 5/7/2012

15 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 5/7/2012

16 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. 5/7/2012

17 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 5/7/2012

18 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 5/7/2012

19 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 5/7/2012

20 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. 5/7/2012

21 E.g. Initial Assessment Session (90801)
Data: Client is 35 yr old African American male presenting with his spouse, Tameka (age 30), for couples therapy. Couple reports high conflict, low intimacy, and low satisfaction for approximately 15 months following the death of their second oldest child. Writer discussed couple’s preferred outcome for therapy as well as their marital relationship. Couple agrees to commit to a minimum of 6 sessions. Also discussed informed consent including HIPAA, Confidentiality, and client rights. Writer initiated a biopsychosocial assessment and conducted a risk assessment: client reports occasional binge drinking. No reports of homicide or suicidal ideation at this time. Assessment: Client’s symptoms include depressed mood, grief, mild anxiety, and bouts of excessive drinking suggesting initial diagnosis of Adjustment Disorder with Mixed Emotions. Rule out diagnosis of substance abuse and dependence. Spouse, Tameka, presents with symptoms of depressed mood, anger, and irritability. Tameka also reports lifelong history of being treated for depression. Client’s current GAF = 53. Tameka’s GAF = 51. Plan: Writer provided information for support group for parents grieving the loss of child offered at West Allis Memorial Hospital. Writer will coordinate Tameka’s care with her prescribing psychiatrist. Writer also provided information for outpatient medical services because client reports he has not received a physical examination in over 5 years. Writer will provide CAGE assessment for problem drinking at next session, and begin a course of marital therapy. 5/7/2012

22 E.g. Follow-up / Standard Session (90847)
Data: Couple presents today under duress, reporting that this past week couple had an argument in which Tameka implied that client was somehow culpable for their child’s death. This resulted in client leaving the home and getting drunk. Writer processed event with couple, and coached partners to discuss their grief in a softening tone. Writer then discussed ways to maintain healthy boundaries at home and to limit challenging conversations to therapy sessions for now. Lastly, writer discussed specific treatment goals for couples therapy. Assessment: Dx GAF = 53. Writer provided CAGE assessment. Results indicate pattern of alcohol abuse, but not dependence. Writer also connected with Tameka’s psychiatrist and arranged for an office visit. Dr plans to increase SSRI dosage for a minimum of 9-12 months. No other risks identified at this time. Plan: Writer will provide education and resource information regarding alcohol abuse, and review marital therapy treatment plan at next visit. 5/7/2012

23 E.g. Discharge Session (90847)
Data: Couple presents today for their final marital session. Couple reports increased intimacy, decreased conflict, improved communication skills, and high relationship satisfaction. Client reports elimination of binge drinking pattern. Tameka reports better management of depressive disorder. Discussed progress on treatment goals as well as plans and recommendations for aftercare. Assessment: Dx GAF = 63. Couple completed all treatment goals and have made significant improvements in the quality of their relationship. This completes a course of 13 marital therapy sessions. No additional risks have been identified. Plan: Couple will continue with grief support group at West Allis Hospital, and engage in supportive activities at their local faith community. Couple meets criteria for discharge and will terminate treatment at this time. 5/7/2012

24 Wisconsin Code of Conduct
MPSW – 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. 5/7/2012

25 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. 5/7/2012

26 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 5/7/2012

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