Client Records and Case Notes

Video Transcription

[MUSIC PLAYING] Back for more fun-- this lesson will discuss types of medical progress notes and necessary components for creating and maintaining the notes. Medical record progress notes are not the same thing as psychotherapy notes. The medical record progress note is an objective account of the session. Psychotherapy notes are subjective accounts, opinions, interpretations, and direct quotes related to the session. There's a risk of keeping psychotherapy notes because you may be accountable for what is written subjectively in there. More about this in a bit.

So for now, this lesson will prepare you to be able to identify necessary components for case notes and to learn various options for maintaining ethical case notes. Specifically, we'll be covering the following-- creating the medical record progress note; types of medical record progress notes; maintaining the medical record progress notes; maintaining psychotherapy notes; retention, release, and destruction of medical record progress notes.

Critical stuff here, so taking notes may be helpful. When writing progress notes, I always envision a stern-looking attorney looking over my shoulder and reading my case notes as I write them. As crazy as this game is, it has come to be very handy. Any time attorneys or judges subpoena your records, then you are liable for explaining everything that you've written.

If opinions or guesses or personal thoughts are included in your notes, then this can be used against your clients or used against you. Stick to the facts is what I tell my counseling students. Keep it basic and clear, like in the following, which are based on common best practices for medical record progress notes-- date of service; beginning and end time of the session; reason for the visit; notable features of a mental status assessment-- example is suicide or homicidal ideation; type of treatment provided-- that is, individual, group, family therapy, et cetera; modality of intervention-- that's CBT, solution focused, et cetera; progress toward goals; treatment plan; homework and efforts to complete homework; diagnosis; next appointment date; your signature or electronic signature; and date note is completed; no show, cancel, or reschedule status.

Various ways exist for you to organize the medical record progress notes. The most likely way that the note will be organized is dictated by the type of notes usable from within the electronic records system. The following are various types of progress notes, and you'll need to determine which is best for your practice. You can google each type of note to find out more information about writing the specific types of notes.

Maintaining progress notes is a necessary responsibility. So if you are using an EHR or any other form of practice management system, you'll have to regularly add notes each time you see a client. This includes an actual session, sending or receiving paperwork, and documentation of phone calls. Additional examples of documents included in the medical record progress note can include-- legal documents, such as custody, probation, or police records; treatment documents, such as pictures of artwork or sand tray works; assessments, audio and video recordings. You'll need to become familiar with mental and behavioral health standard abbreviations in order to make notes quicker, such as Tx for Treatment or Dx for Diagnosis. Lists of abbreviations can be found on the internet.

Now we turn from medical notes to psychotherapy notes-- big difference here. These can include thoughts, observations, opinions, or hunches that you have and want to keep track of. These notes can remain protected, as HIPAA a law makes provisions for professional discretion in regards to the release of psychotherapy notes. Now this means that a sound rationale may keep you from releasing the notes, even if requested. If you are willing to release your psychotherapy notes, a separate release is necessary in order for a client to receive them.

You are ethically mandated to release medical progress notes to clients who sign an ROI, a Release Of Information form. You may charge, typically a few dollars per page, for the release of medical records and progress notes, but you cannot withhold medical records due to nonpayment. Best practices include a 10-year retention plan with irreversible disposal of the medical record thereafter. Although some counselors keep notes indefinitely.

So here's what we covered in this lesson-- first, creating the medical record progress note; next, types of medical record progress notes; maintaining the medical record progress notes; maintaining psychotherapy notes; retention and release and destruction of the medical record progress note.

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