● Write what could be comfortably shared with the client. ● Write records logically. Ensure that charting has some relevance to the presenting problem or the guiding treatment plan. If charted information is not pertinent to either, it should not be included. “Usefulness requires specificity, and vague writing might be construed as indicating incompetence” (p. 31). ● Avoid modifiers (such as soon or sometime) that are abstract or could leave room for doubt. Ultimately, according to Mitchell (2007), records should be understandable and accountable. Although HIPAA does not specify what is required in a medical record, according to Groshong and Philips (2015), the following must be included to meet behavioral health guidelines. ● Billing information and payment records ● Formal evaluations ● Collateral contacts, including release of information (ROI) for all ● Records from other providers with ROI ● Counseling session dates, with start and stop times ● Modalities and frequency of treatment Overall Chart Organization Chart organization and content may differ across settings. Organizations can require specific and structured information, whereas private practitioners have more flexibility as to order and organization. Bodek (2010) provides a framework for organizing a patient record for healthcare settings and advises that a file folder exclusive to each patient be maintained. The folder would consist of: ● Demographic information, including insurance and referral information ● Intake information, including assessment, evaluation, and initial history ● Service or treatment plan ● Progress notes ● Referrals or consultations made, collateral reports, and test results ● Correspondence from other practitioners ● Correspondence with patient or collaterals ● Billing records ● Informed consents/authorizations or other privacy- related information releases Consents and authorizations do expire, so records should contain original and updated forms so that the history of consent to services, communications, and such is evident (Hoffman & Herveg, 2021). In addition, it is recommended that a Health Insurance Privacy and Accountability Act (HIPAA) compliance folder for each patient be maintained separately from the patient’s clinical record and psychotherapy notes. Another organizing framework, offered by Sidell (2015), for a thorough clinical record includes the following five categories.
● Medications ● Diagnoses ● Functional status (activities of daily living [ADL], ability to work, interpersonal capacity) ● Medical/physical problems ● Community contacts, including phone calls, emails, or texts ● Treatment plan and goals ● Symptoms and prognosis ● Progress in each session ● Disclosure forms and informed consents signed by licensed professional and client ● Presenting problem(s) or purpose of visit ● Referrals to and results of formal consults ● Progress notes sufficient to support responsible clinical practice for the type of orientation/therapy used All digital medical records should be backed up regularly and kept in encrypted format, with frequent changes in passwords. Although there can be both medical record and psychotherapy notes, information cannot be put in psychotherapy notes to avoid putting it in the medical record (Groshong & Phillips 2015). HIPAA regulations have affected how client records are organized and what may be included. Documentation is often considered synonymous with record keeping; however, documentation encompasses many aspects, formats, and types of record keeping. To distinguish among the various types of records, the following definitions are offered. ● Mental health records: These are patient records related to the evaluation or treatment of a mental disorder. These records include substance abuse (drugs and/ or alcohol) records (Moline et al., 1998). Typically, behavioral health documentation is noted in a separate section of the electronic health record (EHR). ● Patient medical records: These are records maintained in any form or medium, by or in the custody of a healthcare provider, that relate to a patient’s health history or diagnosis, or the treatment provided. Patient records do not include information given in confidence by a person other than another healthcare provider or the patient. ● Psychotherapy notes: HIPAA regulations define psychotherapy notes as notes recorded in any medium by a healthcare provider who is a mental health professional that (a) document or analyze the content of conversations that took place during a private counseling session or a group, joint, or family counseling session and (b) are separated from the rest of the client record. Psychotherapy notes (as compared to medical records) do not include medication prescription and monitoring; counseling session start and stop times; the modalities and frequencies of treatment furnished; results of clinical tests; or any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date (Thompson, 2020). Several mental health provider associations have debated this ruling. HIPAA specifies that “psychotherapy notes are held to a higher standard of protection because they are not part of the medical record and never intended to be shared with anyone else” (Bodek, 2010, p. 16). If it were true that psychotherapy notes are not intended to be shared, there certainly would be less cause for concern.In addition to the client record, a HIPAA compliance folder for each client must be maintained. Furthermore, HIPAA specifies that psychotherapy notes are to be kept separate from the rest of the individual’s medical record, including the
1. Identifying information 2. Consents and releases
3. Assessments and treatment plans 4. Progress notes and service reviews 5. Communication with and about clients
In the early days of psychosocial intervention, the purpose of documentation was client service delivery. As patients’ rights gained prominence in the 1980s, the importance of clients’ rights to privacy was recognized. The 2003 passage of HIPAA actually legalized parameters of documentation content, such as confidentiality, informed consent, and distribution.
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