Client, Patient, or Name: Which to Use in Mental Health Documentation?

Client, Patient, or Name: Which to Use in Mental Health Documentation?

“What is the proper way to refer to a client when writing my notes?  Do I use their first name, or do I refer to them as ‘client’ or ‘patient,’ which is their role in our relationship?”

I get this question a lot and am fond of answering, “yes.” Almost everything in mental healthcare is in shades of gray. This question is no different. Psychotherapists can use either client, patient, or the client’s name. It is a personal preference. Choose what you are comfortable with or what your agency tells you t use. If you’re in private practice, you get to decide. I’m comfortable with “client” so that’s what I will use in the rest of this blog post.

When it comes to whether you write “client” or use the client’s name, I have heard people on both sides of the “argument” passionately proclaim their opinion as if it has a moral implication. 

Passionate Opinion 1: Refer to the Client by Their Role

One attorney I spoke with said it is considered more professional to refer to the people we work with as “client.” The reasoning is that this approach helps maintain a consistent, objective tone, especially when records might be shared among multiple professionals or with the client.

This is what I do, but I am “old school” in this regard. I have been a therapist so long that when I read the client’s name in progress notes, it seems like an intrusion into the client’s life in a way I don’t belong. (This is my experience, and I know it is a bit extreme.)

Passionate Opinion 2: Refer to the Client by Name

Another attorney said to use the client’s name because it is more personal and client centered.  This way of personalizing treatment seems to be a recent trend but has not become a standard.

It is a similar idea to using the client’s own words when writing client goals in a treatment plan and using a client quote in the progress note. Insurance companies like to read what the client wants and what the client is doing in their own words because it personalizes the documentation. I my mind, this comparison legitimizes using the client’s name even though I can’t bring myself to do it.

Bottom Line: You Can Choose

An insurance company will not penalize a therapist for using the client’s name. Documentation for insurance companies must fulfill all the requirements and justify medical necessity. Period.

A professional board will look for professionalism. Professionalism does not depend on whether one uses “client” or the client’s name. It is possible to use “client” and be judgmental. It is equally possible to use the client’s name and be professional.

Be Consistent

Avoid being inconsistent. Do not use the client’s name for some clients and the role for other clients. The discrepancy could look like you are playing favorites or feel “closer” to some clients than to others.

How to Decide Between Client Name and Role

Consider these questions:

1. Who are your clients?
2. If your clients read your documentation, what do you think they would be comfortable reading?
3. What are you, as the therapist, comfortable writing?

The answer to these three questions may not be the same. Herein lies the dilemma and where choosing what to write represents part of your overall approach to clinical practice. If you are unsure, it may be best to go with the old school method. You can change your approach later as long as you change it for everyone. 

Bottom Line

There is no right or wrong answer. Nor does the decision on what to write involve a moral choice though it may involve a clinical one. Be professional, consistent, and make sure your documentation for insurance companies fulfills all the requirements and justifies medical necessity.

If you want to learn documentation requirements and how to document your clinical work from intake to discharge, check out Documentation Wizard’s online training, Misery or Mastery^®: 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.

Beth Rontal, LICSW, a private practice therapist and the Documentation Wizard® is a nationally recognized consultant on mental health documentation. Her newest initiative, Membership Circle, is designed to empower psychotherapists to master documentation with expert guidance, efficient strategies, and a supportive community. Her Misery and Mastery® trainings and accompanying forms are developed to meet strict Medicare requirements. Beth’s Documentation Wizard® training program helps clinicians turn their clinical skill and intuition into a systematic review of treatment that helps to pass audits, protect income, maintain professional standards of care, reduce documentation anxiety and increase self-confidence. Beth’s forms have been approved by 3 attorneys and a bioethicist and have been used all over the world. She mastered her teaching skills with thousands of hours supervising and training both seasoned professionals and interns when supervising at an agency for 11 years.