There are inherent tensions in clinical record keeping between potentially conflicting purposes, such as facilitating and coordinating care, establishing and measuring treatment goals and progress, complying with 3rd party insurance requirements, responding to external requests for disclosure (e.g., Family Court, Workers Compensation) and all the while staying on the right side of HIPAA rules regarding "PHI" "Psychotherapy Notes" "Informed Consent" Confidentiality and "EHR" just for starters.
This forum is dedicated to an ongoing discussion with the goal of building a repository of consensus standards, comments and resource links available to HPA members.
As a point of departure, please consider and comment on the attached Treatment intake template.pdf, which is one national insurer's published template for behavioral health intake data collection for all patients. The implication of course is that the detail and specificity required by this template may be used to judge the clinician's contractual compliance, competence and justification for treatment and payment of services. After a bit of dialog, I will attempt to summarize the discussion in one or more Consensus Practice Pointers or Frequently Asked Questions (FAQ) pages for permanent HPA member reference.
Richard Kappenberg has offered these observations as to why we write patient notes:
- The first purpose of the notes is to provide enough information for us to treat effectively. That is, to help remind us of what symptoms and circumstances have present for our patient and what treatment we have provided (along with its impact on the symptoms).
- The second purpose is to provide enough information for someone else to treat the person effectively in our absence. We need to provide notes that can be read by another practitioner and that would allow the new practitioner to understand the symptoms, circumstances and treatment already rendered so as to effectively continue or enhance the treatment for the patient.
- We also need to justify to insurance carriers the need and appropriateness of the services provided.
- And we need to have information from our notes in case we are called upon (voluntarily or not) in a patient's legal matters, whether civil (such as divorce and custody) or criminal (such mandated reporting).
- We may also have to justify to the court or other authority the correctness of our diagnoses and treatments of a patient in case of malpractice issues.
- Last but not least, we are tasked with protecting certain information from access by others not approved to receive that information (e.g., alcohol and drug issues, HIV status).
