● 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.
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 HIPAA compliance folder (Bodek, 2010). This regulation sets up a baffling conundrum in that healthcare facilities usually maintain a single consolidated medical record for each client that includes all consultations, including behavioral health interventions. As a result, the therapist may maintain their own clinical or shadow notes, which may be considered “personal” but are nevertheless subject to the same legal scrutiny as the official record. Some clinicians argue from a minimalist perspective that the less that is written, the less there is that can hurt the clinician or the client. Under the guise of protecting client confidentiality, these clinicians may err on the side of maintaining too little documentation. Some practitioners have argued against keeping detailed records, based on the contention that confidentiality can be best protected as a way to avoid litigation with no documentation at all, particularly if the client requests minimal documentation. Although the professional debate is not over, this argument may be shortsighted in the present digital and litigious era; in fact, lack of documentation could potentially make a practitioner more liable and simultaneously do a disservice to the client (Wiger, 2022). Other clinicians may provide too much documentation, thinking that more is better. This practice may also be problematic in that superfluous information may confound what is crucial to the client’s treatment. It is difficult to imagine that behavioral health practitioners can remember every detail about a client without referring to their records. For example, imagine the therapeutic rupture that would result if a therapist in session confused one client’s history with that of another client. The clinician’s review of their thoughtful records prevents such an unnecessary error. Imagine the reaction of a patient who visited their physician and found that nothing was charted about their medical history, current complaints, or medication prescribed. Likewise, in behavioral health, good record keeping can help establish rapport as a client sees that what they have to say is worth noting, literally and figuratively. Record-keeping content and especially format may vary considerably across settings. Agencies dictate the specific format. The APA revised guidelines for record keeping suggest that for practitioners in agencies or private practice, “records document the nature, delivery, progress and results of services” (Drogin et al., 2010, p. 237). Therefore, three kinds of content should exist across settings: (1) General file information such as demographics and reasons and goals for service; (2) substantive contacts, including date and duration with client and collaterals, the context and approach to services, tests, and progress; and (3) supplemental information such as assessment results, measurements or tests, and client journals or drawings.
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. 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 Informed Consent Informed consent has been called the “quintessential document” in the provision of mental health services (Bradshaw et al., 2014). In addition to being one of the first documents to comprise a record, it is one of the best risk-management tools. Informed consent in today’s healthcare milieu demands details not previously considered, including potential benefits and risks of engaging in treatment, the nuances of technology
use, limitations on confidentiality, and mandated reporting. “Failure to obtain or document consent can result in serious consequences, including problems in the therapeutic relationship and legal action” (Bradshaw et al., 2014, p. 3).
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Book Code: SWUS1524B
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