Managed Care

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While at times limited in the their discussions, professional associations do generally include some statement regarding record keeping in their ethical codes. For example, the American Psychological Association (APA) Ethical Principles of Psychologists and Code of Conduct states: “Psychologists appropriately document their professional and scientific work in order to facilitate provision of services later by them or by other professionals, to ensure accountability, and to meet other requirements of institutions or the law” (APA, 1992, p. 1602). While the current (1998) American Association for Marriage and Family Therapy (AAMFT) Code of Ethics appears to remain silent on the issue of record keeping, the newly revised and approved Code (effective 7/1/2001) states: “Marriage and family therapists maintain accurate and adequate clinical and financial records” (Family Therapy News, 2001, p.10). The National Association of Social Workers (NASW) Code of Ethics presents a number of clearly stated standards including: “Social workers should take reasonable steps to ensure that documentation in records is accurate and reflects the services provided,” and “Social workers should include sufficient and timely documentation in records to facilitate the delivery of services and to en sure continuity of services provided to clients in the future” (NASW, 1996, p. 14). And finally, record keeping is also addressed in the American Counseling Association (ACA) Code of Ethics and Standards of Practice in the standard that states: “Counselors maintain records necessary for rendering professional services to their clients and as required by laws, regulations, or agency or institution procedures” (ACA, 1995, p. 5).

Barnett in an article entitled “Document This!” (APA Division of Independent Practice website) has outlined essential reasons why documentation is an important part of the work of any therapist. Such essential reasons can include providing better care for clients, providing continuity of care if clients return for treatment at a later date, assisting clients in the event of litigation in which the client’s mental condition and treatment is an issue, and meeting the requirements of ethics codes. Barnett includes in his extensive list and I would emphasize: protecting the therapist in the event of a malpractice suit, a complaint before a licensing board, and/or a complaint before an ethics committee. Regardless of whether or not the argument could be made that the progress note example presented above would meet the ethical requirements of professional associations such as APA, AAMFT, NASW, and ACA, it is doubtful that the note would be helpful to a therapist in a court action, appearing before a licensing board, or responding to an ethical complaint. Further, it could easily be argued that the entry would provide little benefit to another therapist now working with the client and wanting to have a better understanding of the previous therapy. At very least, it is hard to imagine that even the individual who wrote the note would at a later date be able to easily reconstruct the content of the entry in any meaningful fashion.

¹ The phrase “risk managed documentation” has been used by Eric A. Harris, J.D., Ed.D., Bruce Bennett, Ph.D., and Jeffrey Younggren, Ph.D., in workshops sponsored by the American Psychological Association Insurance Trust (APAIT) on risk management.

What constitutes “risk managed documentation?” In 1993, the American Psychological Association published the Record Keeping Guidelines which provided psychologists with at least some direction regarding the content of clinical records, maintenance of records, record retention, and other elements of record keeping (APA, 1993). However, this document, while certainly a potential source of help, tends to present information that is limited in its scope and not as practical as some mental health professionals might want, and does not answer the question, “What is risk managed documentation?”

In risk management workshops presented by the American Psychological Association Insurance Trust (APAIT), Eric Harris, J.D., Ed.D., has presented a succinct yet encompassing description of risk management: “(the) prospective assessment of retrospective evaluation” (Younggren, personal communication). Younggren (2000) described the goals of general risk management as reducing the possibility of a malpractice suit or disciplinary action , increasing the possibility of winning a suit or having a positive outcome before a disciplinary board, and controlling damage if a suit or disciplinary action is filed. Generalizing from those goals, I would argue that risk managed documentation is the critical tool needed to achieve those goals. Risk managed documentation is far more than just a brief entry describing a contact with a client. Rather, it is detailed and extensive enough to not only provide quality care for clients but also to reduce the likelih ood of suits or complaints, to increase the probability of success in the event of such negative actions, and to reduce damage in the event of suits or complaints. Risk managed documentation provides the therapist with an increased level of protection while at the same time addressing requirements of professional codes of ethics. It is also my contention that by creating risk managed documentation, the clinician also increases the likelihood that the client benefits because specific problems, goals, and objectives are outlined (rather than just “talking about” whatever comes to mind), the notes are comprehensive should the client’s mental status be called into question, and future therapists could easily provide continuity of care if treatment is sought at a later date with another clinician.

If risk managed documentation both serves the client and protects the therapist, then what should be included in the notes of therapists? Koocher and Keith-Spiegel (1998) have suggested that a number of points should be addressed and included in the content of clinical case records, and the following are from their text Ethics in Psychology and include:

1. Identifying information including name, address, birth data, marital status, telephone number, etc.
2. First contact in which the date of the initial contact, referral source, and documentation that informed consent is addressed (including discussion of limits of confidentiality which is required by the 1992 APA Ethics Code).
3. Relevant history and risk factors which may include social, medical, education, and vocational history, assessing danger to self, others, children, etc., and risk for impulsive acts. For example, the authors suggest asking clients directly what the most violent “thing” is they have done in the past and are there thoughts of harming, hurting, or killing themselves or others. Further, Koocher and Keith-Spiegel suggest getting a signed consent and requesting records from previous therapists.
4. Medical status in which information is collected about medical and health related problems. I always ask when the most recent comprehensive medical evaluation was completed, and if one has not been done within the last year, I encourage the client to have a physical examination.
5. Medication profile which includes not only medications (helpful to know past and present psychotropic medications) but also over-the-counter drugs, alcohol, tobacco, and illicit substances, and I ask abo ut caffeine consumption as well.
6. Why the client is in your office. Koocher and Keith-Spiegel suggest that the therapist include “ . . . a full description of the nature of the client’s condition, including the reason(s) for referral and presenting symptoms or problem. Be sure to ask clients what brought them for help at this point in time and note the reasons. Incorporate these in treatment planning, with subsequent revisions as needed” (p. 139).
7. Current status includes a mental status examination and a functional assessment of how the client is fu nctioning emotionally and cognitively.
8. Diagnostic impression includes clinical and diagnostic impressions using the most current Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.
9. Treatment plan is developed in consultation with the client and includes specific short-and long-term goals and therapeutic activities.
10. Progress notes should include documentation of progress toward goals and include “. . . clear, precise, observable facts (e.g., “I observed”; “the patient reported” . . .) (p. 139). The authors make an important point that I believe every clinician should remember: “As you write, fantasize the patient and his or her attorney looking over your shoulder” (p. 139). I would add that it is important to also imagine that your malpractice attorney, a licensing board, an ethics committee, and your client are also looking over your shoulder. Hence, Koocher and Keith-Spiegel suggest that as the note is written, avoid the temptation to theoretically speculate, include reports of unconscious content, be cute or sarcastic, and to at all times portray yourself as the dedicated professional.
11. Psychological Testing if done should be included.
12. Client homework assignments that have been assigned, completed, or not completed should be maintained in the record.
13. Service documentation includes noting each visit and response to the interventions, and each should be dated and signed (including the supervisor’s signature if such is required). I also suggest documenting telephone contacts (emergency or routine), and certainly, all emergency contacts are documented thoroughly. If I have had a contact with a client outside of the office, e.g., saw the client in a restaurant, mall, etc., and the client attempted to engage in some “therapeutic discussion,” I document this just to be on the safe side.
14. Document follow-up including calls made for missed appointments, especially if thereare concerns such as potential dangerousness. If clients prematurely terminate and there are concerns, again seriously ill or concerns about danger to self or other, written follow-up might also be important. Keep records of all correspondence with clients as well as documenting telephone contacts.
15. Obtain consent - the clinical record should include all signed consent forms, registration forms, release of information forms, and so on, and ideally these are signed, dated, and witnessed by a third par ty.
16. Termination notes should also be included. This may be a summary of treatment in the case of planned termination. In my practice, I always “leave the door open” for future booster sessions and follow-up, but still note that regular sessions have been completed and the client will be seen on an as needed basis.

Younggren (2000) also addresses the content of risk managed records, and since there is considerable overlap with Koocher and Keith-Spiegel (1998), I will only present the list provided by Younggren in his APA Insurance Trust workshop “Legal and Ethical Risks and Risk Management in Professional Psychological Practice:”

1. All identifying information
2. All billing and financial information
3. Reason for referral
4. Client’s reasons for seek ing help
5. Evidence of informed consent
6. History
7. Records of past treatment
8. Consultation and/or supervision notes
9. Diagnosis
10. Testing and test reports
11. Medication consideration
12. Risk factors
13. Goals and potential roadblocks to goals
14. Session notes.

Younggren (2000) adds that good records (and I consider “good records” as risk managed records) provide a foundation for proper treatment and diagnosis, assist the clinician in providing good treatment, offer important information to future treating professionals, assist in gaining third party reimbursement (e.g., insurance companies and managed care organizations), and provide evidence of quality care. Further, such records provide evidence that therapists care about their clients, took into account the information the therapist had about the client, considered the various pros and cons of options, consulted with peers as needed/indicated, and chose and implemented a professional intervention strategy. Younggren notes that there are still practitioners who offer the bad advice to keep no records or very limited records. As hopefully we all know, if it is not written, it did not happen! Good advice is to keep good records, especially with high risk clients, to keep records secure and safe, and to know laws regarding client access to records and retention of records. If no such statute exists consider professional standards, guidelines, or ethics codes, e.g., for psychologists if there is no legal guideline, the APA Record Keeping Guidelines (APA, 1993) recommend maintaining the complete record for a minimum of 3 years after the last contact with the client, and the complete record or a summary be maintained for an additional12 years before records are destroyed. (And, if the client is a minor, the time period does not begin until the age of majority is reached.)

By now, you may be experiencing at least some degree of concern, even anxiety. If so, I believe that is good! From introductory psychology, we remember that a moderate degree of arousal results in improved performance (Yerkes-Dodson Law, right?). You may be thinking that your current record keeping approach is lacking at best. Certainly, when I decided to go into solo independent practice in1998, I recognized that my handwritten, “process” notes offered an opportunity for improvement.

But, who has time or can remember to address the important elements outlined above? I allow 15 minutes between appointments to write notes, return phone calls, and maybe even have a quick snack bar for energy. In the past I attempted to create forms that I could use after each session, but this never seemed to work. While in group practice, I had purchased treatment planning and documentation software, but this generally just gave me the opportunity to write a narrative entry without any guidance in addressing the critical areas of risk managed documentation.

Fortunately for the busy practitioner, there are tools available which, in my opinion, provide the needed “guidance” to create not only risk managed records, but also excellent documentation of the treatment provided. Ed Zuckerman, Ph.D., provided a review in 1997 of computer billing and office management software (http://mentalhelp.net/guide/pro24.htm) which I found extremely helpful when initially reviewing available software. After reviewing a number of documentation programs, I chose QuicDoc and QuicForms (available from DocuTrac, www.quicdoc.com), and without a doubt this was one of the best practice decisions I have ever made. QuicDoc has given me the needed tool to create comprehensive intake and progress notes, each of which are designed to include the elements described early. Not only are the elements associated with risk managed documentation included, but also I am able to create specific goals and objectives which facilitate the treatment pro cess. QuicForms is used to create treatment plans for various managed care organization which saves considerable time.

And, speaking of saving time, when I was in group practice I would dictate my intake note after the first session. Not only was this expensive (transcription services are not cheap), but many of the critical elements of risk managed intakes were easily missed. Since I started using QuicDoc, I have found that it actually takes me less time when using QuicDoc than when I would dictate. (But, I should note that I type pretty well, and time will certainly be related to typing skills.) My progress notes take between 2 to 4 minutes to complete immediately after the session, and I can cover session content (themes discussed, change in stressors, session content), session characteristics such as client’s motivations, resistance, cognitive focus, cognitive flexibility, emotional expression, use of session, and treatment compliance, interventions (e.g., detecting and disputing irrational beliefs, relaxation training, etc.), response to these interventions, and homework assigned and results of homework. Plus, progress notes can be personalized to include whatever components the therapist prefers, and each n ote includes date of session, the session number (I like to review every fourth sessions so I know if it is the 4^th, 8^th, etc.), CPT service code, type of visit (scheduled, emergency, etc.), client’s name, and provider’s name, address, title, and license number(s).

I was so impressed with QuicDoc that over time I got to know the principles in the DocuTrac, Inc. organization, and eventually I was offered a position as Executive Director, Enterprise Division. So, while I may be somewhat biased today, I had previously written a review (long before I became affiliated with the company) that included many of the reasons why I have found the software so valuable in my practice. (That article can be found at the Division of Independent Practice website under News & Views, Technology, and select “Therapist Helper and QuicDoc:” While it is certainly possible to develop a documentation strategy that will incorporate the elements of risk managed records, the question is does the current method being used provide those components? If you were sued or charges filed with a licensing board or an ethics committee, would your progress notes be your “best friend” or “worst enemy?” If a client’s malpractice attorney were reading your notes over your shoulder, would he or she be smiling or frow ning? How about your attorney? If your attorney is smiling and you are comfortable, then hopefully you have created the risk managed record. If the plaintiff’s attorney is smiling and you are cringing as you read your own intake and progress notes, then it might be advisable to reconsider how you are creating your notes and consider this an opportunity for improvement.

References:

American Association for Marriage and Family Therapy. (2001). Revised AAMFT code of Ethics. Family Therapy News (December 2000/January 2001), 9-11.

American Association for Marriage and Family Therapy. (1998). AAMFT code of ethics. Washington, DC: Author.

American Counseling Association. (1995). Code of ethics and standards of practice. Alexandria, VA: Author. Retrieved February 29, 2001 from the World Wide Web:
www.counseling.org/resources/codeofethics.htm

American Psychological Association. (1992). Ethical principles of psychologists and code of conduct. American Psychologist, 47 (12), 1597-1611.

Barnett, J. (Publication Date Unknown). Document this! Retrieved March 16, 2001 from the World Wide Web

Committee on Professional Practice & Standards: A Committee of the Board of Professional Affairs.(1993). Record keeping guidelines. The Psychotherapy Bulletin, 28(1), 15-17. (Also in the American Psychologist, 48, 308-31 0.)

Koocher, G. P., & Keith-Spiegel, P. C. (1998). Ethics in psychology: Professional standards and cases (2nd ed.). New York: Oxford University Press.

National Association of Social Workers. (1996). Code of Ethics of the National Association of Social Workers. Silverspring, MD: Author. Retrieved March 16, 2000 from the World Wide Web www.naswdc.org/Code/ethics.htm.

Younggren, J. Personal communication, April 1, 2001.

Younggren, J. (2000, September). Legal & Ethic Risks and Risk Management in Professional Psychological Practice: Sequence I: General Risk Management Strategies. Workshop presented in Memphis, TN and sponsored by the Tennessee Psychological Association and APA Insurance Trust.

©2001 Ed Nottingham, PhD, ABPP