Elizabeth Irias also has a website that offers CEU's (some free and some you have to pay for) that you can check out here: https://clearlyclinical.com. Here are some highlights about note writing from this training.
Notes should not be short and vague
- We must include who, what, where, WHY, and when.
- Therapists often forget the WHY.
FRAUD - this is scary!!
Fraud does not have to be intentional to be criminal!! Here are red flags that auditors are looking for in regards to finding fraud:
- Copied and pasted phrases or sections (I can tell you that this is occurring in notes that are coming from OC therapists, and we need to correct this!)
- Missing entries
- Frequent revisions and entries (The more we modify a note the less integrity it has. This means when a note gets rejected multiple times it is decreasing the integrity of the information being written by the therapist. So please be proofreading your own notes to ensure they do not have to be rejected by billing supervisors).
- Service overlap
- Inaccurate charting
Companies create specialized software that will comb through your notes to look for duplicate content both across charts and within a client's chart - so if you write the same thing in your notes for multiple clients they will catch this. This also applies to treatment plans. If you use the same treatment plan objectives for multiple clients this is not individualizing your treatment to the client's specific needs.
Medical Necessity
Requires that there is a legitimate clinical need and that services provided are an appropriate response. Imagine a doctor performing a procedure that wasn't medically necessary - this would be dangerous!! It is the same concept for us as therapists.
Medical necessity - must meet the following criteria:
- Indicated (relevant diagnosis)
- Appropriate (treatment meets the client's needs)
- Efficacious (interventions or service will be effective)
- Effective (treatment actually worked)
- Efficient (intensity, frequency and duration of services are logical and not wasteful)
State of Colorado’s Definition:
- Medically necessary means a covered service that will, or is reasonably expected to prevent, diagnose, cure, correct, reduce or ameliorate the pain and suffering, or the physical, mental ,cognitive or developmental effects of an illness, injury or disability; and for which there is not other equally effective or substantially less costly course of treatment suitable for the client’s needs.
What needs to be in your notes
Safety F.I.R.S.T. Mnemonic
- F = Functional Impairment
- I = Interventions
- R = Response
- S = Symptoms
- T = Therapeutic Interpretation
Functional Impairment
- How does the individual's condition or situation impact his/her/their ability to function in important domains of life like work, school, home, etc?
- How does it affect them?
- Why does that matter?
Interventions
- What treatment interventions did you use, and what was the clinical reasoning behind it?
- Example: “Therapist encouraged the client to identify the pros and cons of switching majors in college”
- Why did you do this? -- I did it “In order to” (insert reason) In order to improve the client’s consequential reasoning or in order to assist the client in decision making.
Response
- How did the client respond to you and your interventions?
- Client became agitated, were they open to trying the intervention, did they appear defensive, etc.
Symptoms
- Document both the symptoms you observe and the reported symptoms by the client
Therapist’s Intervention
- This may include:
- Treatment compliance/lack of compliance
- Clinical Impressions
- Progress
- Relapse potential
- Prognosis
- Exercise of clinical judgment
- Plan
How much to write
Rule of thumb: write at least one intervention AND one response for every 10-15 minutes of session. 45-minute session = At least 3 defined interventions and at least 3 client responses. Since the majority of our sessions are 60-minute sessions, this should be 4 and 4.
How to avoid novel-writing
- Ask these questions:
- Have I documented the clinical safety/risk factors?
- If I had 30 seconds to present this session what would I say?
- Why do I think the client needs this treatment?
- Is this a summary of the session, or is it a play-by-play?
- Is this sentence generally relevant to the gist of the note?
- Does the client's actual quote explain this better than my clinical interpretation (i.e. - psychobabble)?
Be mindful of the tone of your notes
Tone matters! Use clinical and neutral language.
- Crystal Ball effect: “May” or “will” - instead of “will” use the client is at high risk of….etc.
- Watch your verbiage:
- “Manipulative” - instead use “client uses maladaptive ways to get their needs met that violates the rights of others. Unless you are quoting a client, then use their language
- Imagine a client reading your note.
Notes need to be individualized
Provide details - Be cautious when using check boxes or repetitive language. There needs to be enough detail to show how the note differs from previous sessions.
- Copy and Paste. Must be used carefully, only when appropriate, and only when specifically applicable. Remember this is a big red flag for fraud!!