Transcript WAMFT Writing Progress Notes

Writing Progress Notes
Robert W. Marrs, MS, LMFT
On Behalf of Wisconsin Association for Marriage and Family Therapy
5/7/2012
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
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.
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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.
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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.
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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.
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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.
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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
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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
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One of the most common progress note formats is DAP: Data / Assessment /
Plan
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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.
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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
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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
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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
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Progress Notes: Additional Tips
 Consider how the patient is represented
 Avoid using words like “good” or “bad” or any other words that
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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
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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
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Progress Notes: Additional Tips
 Below are the different types of progress notes written during the
course of outpatient mental health treatment:
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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.
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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
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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
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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.
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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.
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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.
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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 309.28. 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.
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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 309.28. 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.
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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.
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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.
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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
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