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
Evaluation
Synthesis
Analysis
Application
Comprehension
Knowledge
Bloom’s Taxonomy for Documentation (almost verbatim,
APAIT, 2009) With apologies to Harris & Younggren
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