QUESTION: Can You Combine the Intake Summary and the Diagnostic Session Note?
My EHR combines the Intake Summary and the Diagnostic Session Note and calls it the Intake Session Note. What do you think of combining them?
I prefer the documents to be separated, but there is no one right answer. This blog provides guidelines to help you decide on which method you use. It also includes my preference as someone who routinely reviews clinical documentation. (To be totally transparent, my opinion dates me as an “old-time” therapist.)
The Diagnostic or Intake Summary serves a different purpose than the Diagnostic Session Note.
- The Diagnostic Summary collects client history and informs the treatment plan.
- The Session Note documents that the history was collected and acts as the billing document.
Therefore, it makes sense (to me) that the Diagnostic Summary is a standalone document. Combining the Summary with the Session Note is meant to ease the burden of documentation by speeding up the process. However, I find that combing them can cause problems. The biggest problem lays in shortchanging the collection of a good history. I believe in the value of taking a good bio-psycho-social history and spending the time to do it.
VALUE OF TAKING A GOOD HISTORY
Getting a good history that enables you to write a useful treatment plan, can take two to three sessions. I like to see all the information that informs the treatment plan in one document. I don’t want to search for it over several session notes. Additionally, having the history in one place is an easy way to establish the Golden Thread of documentation.
When using a good diagnostic summary template, the first two to three sessions not only get basic information like medications, psychiatric history, and reason for seeking services, it can also illuminate issues around culture, spirituality, learning differences, loss, racial profiling, immigration, discrimination, LBGTQ issues, fat shaming, bullying, domestic violence, etc. To be sure, this level of history taking involves time. Since therapists are in a constant race to get notes done, time feels scarce. But there is a significant benefit — It can open the door for clients to reveal things they didn’t necessarily recognize as traumatic. Seeing it in black and white can be therapeutic. It is also a way to demonstrate you’re practicing in a culturally competent way. To be crystal clear, it’s only a start, but an important one.
REDUCING CONFUSION / IMPROVING OUTCOMES
Separating the Diagnostic Summary from the initial Session Note may also mean less confusion for the reader who is not familiar with the practice of combining them. Separating the note from the intake also means you can send a blank copy of your Diagnostic Summary to the client and ask them to complete it in time to review together during 1st and possibly the 2nd and 3rd sessions. I find this practice clinically useful and a time-saver.
From what I’ve seen doing documentation reviews, the digital documentation systems that merge the Diagnostic Summary with a Session Note as one document reinforce the practice of shortchanging good history taking for “just getting it done.” In turn, this practice may also shortchange writing a Treatment Plan that is truly meaningful.
WHAT TO WRITE IN THE DIAGNOSTIC SESSION NOTE
Writing the Diagnostic Session Note is simple and takes me about 3 minutes. The interventions for the Diagnostic Session are almost always the same unless you are dealing with a crisis.
Therapist reviewed HIPAA with client, informed consent, practice policies, cancellation policy, got signed releases, and started to take a brief history of presenting problem.
(FYI — the second session’s interventions usually start with, “Continued to take history of presenting problem…)
Everything I teach is based on researched documentation requirements in the context of good clinical practice. When we understand the reasoning, we can apply the requirements in a way that aligns with our clinical practice. If you continue to combine your Diagnostic Intake with your initial Session Note, you may pass an audit, but you may also confuse the reader – and miss a great deal of important information that informs your treatment.
If you want to learn how to document your clinical work from intake to discharge, check out Beth Rontal’s online training, Misery or MasterySM: Documenting Medical Necessity for Psychotherapists. You’ll learn how to translate your clinical intuition into the behavioral language required by insurance companies, while contributing to and reflecting high quality care.