How to Document Changes in Treatment During Covid-19 Without Writing Another Plan

Private practice therapists are expected to write a new treatment plan once a year. What happens when your well thought out plan gets thrown to the wind before it’s time for an update? This scenario may be happening right now since the sudden outbreak of the Covid-19 pandemic. Problems, goals, and interventions may be radically changing because life has changed dramatically. Do you write a whole new plan even if the last one was written 3 weeks before the pandemic became obvious? Or do you scratch the written plan and “start where the client is” without documenting the change?

Do I Have to Write a New Treatment Plan?

This public health emergency is a disorienting bio/psycho/social stressor affecting everyone. It can exacerbate current symptoms, or it can trigger new ones. It can put the focus back on daily coping skills previously stabilized. It can create panic in people who were depressed and depression for people who were anxious.

Are PTSD symptoms exacerbated? Are symptoms for Generalized Anxiety Disorder, once moderate, now back to severe? Is there a new diagnosis? Do you add Acute Stress Disorder or Adjustment Disorder with Depression or Anxiety? You get the idea. This new way of living is affecting people’s mental health and testing everyone’s coping skills. As mental health professionals, we’re tasked with helping our clients get through it in the healthiest ways possible and staying grounded ourselves.

Writing new plans for all your clients is an overwhelming task. If you’re like me, the increased emotional and logistical demands in your personal and professional life are already more than you want to manage. So, unless the therapy is totally different than what you’ve been doing, skip the new plan for now. Document the changes in your session notes, and periodically reference the pandemic in your interventions. If after 3 months, it’s clear that your client’s treatment plan has changed before the year is up, write the new one then. But document the changes in the session notes.

What do I write in my session note to reflect Covid-19?

First, it’s important to indicate in your note that we are in the midst of a global pandemic. Note that the client’s presenting problem has changed and symptoms are either worse or new. (Or less severe symptoms for some!) Perhaps the client is experiencing social isolation for the first time. Maybe symptoms are worse with social distancing. Some clients may be at greater risk of domestic violence because they’re home with her abusive partner. A single mother may be struggling to split her time between homeschooling her kids and working from home. It’s possible that a client who held a high paying job is now unemployed and worried about paying the mortgage.

Write something as simple as, “Covid-19 pandemic causing increased social isolation, irritability, difficulty making decisions.” Or, “Covid-19 pandemic triggering panic attacks and alcohol use.”  It’s like describing the presenting problem in the treatment plan, but you don’t have to write the goals or objectives.  On my session template, I have a place for describing recent changes that impact treatment. This is how I document a change in the treatment plan without writing a new one before it’s due. Find a place on your template to do the same.

Interventions Specific to the Covid-19 Pandemic

Once you’ve documented the changes or new presenting problem in your session note, refer to the pandemic in your interventions. Here is a list 16 different interventions that reflect how treatment has changed due to the pandemic:

1. Processed, normalized, and validated fears around pandemic and its effect on daily life. 
2. Help client develop coping strategies, self-care, and routine during Covid-19 pandemic.
3. Help client identify need for increased connection in this time social distancing.
4. Help client identify negative cognitions associated with pandemic, challenge and reframe them. 
5. Help client with distress tolerance of current Covid-19 pandemic.
6. Help client process impact of pandemic on daily life, work, and interpersonal relationships.
7. Help client evaluate the current situation, identify resources, and create a plan with small practical steps.
8. Reinforced Mindfulness and Emotion Regulation skills to manage symptoms of anxiety and depression related to Covid-19.
9. Processed pandemic’s impact on client’s daily life, work, and interpersonal relationships.
10. Assisted client in labeling thoughts/feelings related to current virus pandemic.
11. Helped client identify the difference between symptoms related to current pandemic and past trauma.
12. Helped client identify a frightened part of their personality and provide it comfort. 
13. Encouraged client to draw fears and put them away in a worry box.
14. Helped client recognize the importance of finding pleasure in little things during this time.
15. Helped client manage their relapse with using food as their only form of comfort.
16. Engaged client in EMDR (EFT, TAT, BrainsSpotting, etc.) to process and reduce anxiety associated with Covid-19 pandemic. 

Justify the change of plan in your assessment.

In your clinical assessment, include why you think the client has de-compensated. Describe what old trauma may be triggered. Explain why the client may be experiencing new or fewer symptoms. 

This may seem like a lot to write in a session note but it’s better than writing a whole new treatment plan. No one knows if insurance companies will stoop to the low of doing audits on our work during this time, but just in case, being a bit OCD may payoff. 

You’ve got this!

This is not rocket science. You’re not looking for the cure for Covid-19. You’re using your clinical judgment, just like you always do.

If you haven’t taken my workshop, Misery or Mastery: Documenting Medical Necessity for Psychotherapists, wrapping your head around all the details of clinical documentation, in general, let alone during a pandemic could be a bit overwhelming. If you need more guidance on how to write treatment plans, document sessions, or manage the administrative side of a private practice, I offer templated forms and online workshops that give you a step-by-step approach to turn your clinical intuition into thorough and effective documentation. Visit DocumentationWizard.com to learn more.