HOW TO DOCUMENT PSYCHOTHERAPY SESSIONS In keeping with HIPAA privacy regulations, BCBSM will no longer review psychotherapy notes if the provider keeps the notes separated from the medical record. Psychotherapy notes are recorded notes that document or analyze the content of conversation between therapist and patient, capture the therapist's impressions about the patient, and /or contain details of the patient's feelings, wishes, and fantasies considered inappropriate for inclusion in the medical record. Clinical notes are required for each individual psychotherapy session. These notes encompass that portion of the medical record that is separate from the aforementioned psychotherapy notes and not a province of HIPAA confidentiality requirements. The clinical notes should include:
- The date of each therapy session
- The length of the session (i.e., start and end times)
- The patient's current clinical status as evidenced by the patient's signs and symptoms. This documents the nature and seventy of the patient's condition as it is perceived during each therapeutic encounter. Examples of pertinent data include reference to continuation or resolution of suicidal ideation, abnormalities identified on mental status examinations, psychomotor retardation interfering with activities of daily living associated with persistence of major depression, etc.
- A statement summarizing the relationship between signs/symptoms and primary focus of the therapeutic encounter (e.g., anxiety and depression linked to problems with self-esteem, poor assertiveness skills, and problems with self-actualization, or paranoid thinking reflective of fear of loss of control of aggressive impulses).
- A statement summarizing the therapeutic intervention attempted during the session (e.g., ventilation, catharsis, or interpreting feelings associated with unresolved conflict).
- A statement summarizing the patient's degree of progress (or lack of progress) toward the treatment goals.
- This should include reference to dynamic changes as well as symptomatic progress (e.g., patient feels less angry, has more awareness of tendency to displace, paranoid ideation remains prominent).
- Clinical notes should include reference to progress of the therapeutic plan established and documented at the start of therapy. Clinical notes that are able to address at minimum the aforementioned seven bullet points will satisfy documentation guidelines for an individual psychotherapy session.
Differences in Types of Sessions Clinical notes may reflect different types of therapy sessions. For example, initial sessions may focus heavily on evaluation while the last sessions may focus on the termination process and plans for self-care. The object is that the notes reflect substantive, dynamic, goal-oriented therapy appropriately designed to treat an active mental disorder. Documenting Treatment Plan Progress. It is fair to expect the clinical record to document thoughtful reflection about the treatment plan every session for patients undergoing crisis intervention or short-term therapy and no less often than every third session for patients undergoing long-term therapy. Infrequent reflection on the treatment plan can prolong the treatment process. Notes about progress toward treatment goals and reassessment of the therapeutic plan help encourage active therapy responsive to change in the patient's condition and timely, appropriate adjustment of the therapeutic plan. Decisions about the medical necessity and intensity of service will be made based on the documentation of the treatment as an ongoing process, and not necessarily on a note-by-note basis (unless minimum requirements are not present). Additional Documentation Requirements.
- Progress notes must be legible and comprehensible
- All progress notes must be signed, with appropriate credentials Information Insurance Information Advertising Rules Supervision
- In group therapy sessions, the number of patient participants (not to exceed fifteen) should be indicated
- In family therapy sessions, the relationship of additional participants should be indicated (e.g., spouse, child, etc.)
- Patient's reaction to therapeutic intervention should be briefly indicated (e.g., patient receptive to therapeutic suggestions, or patient reluctant to comply with recommended medication changes)