How to Document Prognosis for Mental Health

Medicare just added Prognosis to its list of documentation requirements. UGH! One more thing to think about and document. But how?

What Is a Prognosis?

Prognosis refers to making an educated guess about the expected outcome of treatment. Based on the medical model, it’s a prediction of a client’s process and progress. Determining prognosis for a psychotherapy client is not as straight forward as determining the prognosis for someone with heart disease, for example. I thought long and hard about how to document this because prognosis is based on a combination of factors. Given the client’s circumstances, how much healing can happen and how long will it take? 

Prognosis vs. Diagnosis

Prognosis and diagnosis are often confused. While a diagnosis identifies the problem with a label, like depression, anxiety, or Post Traumatic Stress Disorder, prognosis is an educated guess about the outcome of treatment.

What Factors Affect Prognosis?

Prognosis is based on quite a few factors that must all be considered when developing your educated guess. It’s not a simple process but it is worth taking time to think about because it can inform your treatment. Factors that influence prognosis include:

• Age
• Gender
• Duration of symptoms
• How the symptoms are presenting (behaviors)
• Medical history and possible comorbidities
• Family medical and mental health history
• Risk factors
• History of trauma
• Client’s strengths and weaknesses
• Motivation
• Supports
• Access or barriers to care
• Financial resources
• Cultural influences
• Treatment or treatments being used
• Response to treatment

A Necessary Evil or a Useful Prediction?

The factors that go into deciding on prognosis can affect or influence each other.

Example that may lead to a good prognosis:

For example, a teen presents with severe ADHD and anxiety and is struggling in school and with friends. But she is supported by family that knows how to navigate the educational system and get her educational supports. She is motivated to do well, is compliant with medication that helps, and has psychotherapy that helps process distressing thoughts and feelings. She’s able to pay attention in school and learning to read the social cues she needs to make friends. This teen has a good prognosis.

Example that may lead to a poor prognosis:

On the other hand, a different teen may be struggling with ADHD and anxiety but not have a good prognosis. Even if this teen is motivated, he may live in a chaotic household with parents who do not have the financial resources or understand how to navigate a complicated and sometimes hostile educational system. If his motivation is strong enough and he gets the counseling needed to manage the ADHD, heal from the anxiety, has supports at school and learns to advocate for himself, he may also have a good prognosis. Without motivation or supports, his prognosis is most likely poor.

Quantifying Prognosis

Thinking about how to understand and quantify the process, made my head spin. I didn’t want to write an additional 2-page review that justified my professional opinion.

Then I realized that the complexity involved in determining prognosis is dependent on taking a thorough history and writing a good Intake or Diagnostic Assessment. It may not be possible to get all the information you’d like to get in the first few sessions, but you can get enough to make an educated guess. Plus, nothing is written in stone. Prognosis may change with either additional information, a change in circumstances, and/or good treatment.

Finally, I decided to boil down my professional opinion to a simple five-point rating scale. For example: “Given client’s history, supports, and motivation reported in the Diagnostic Assessment, prognosis is 4/5” or some version of this statement.

If you need a good Diagnostic Summary/Assessment, check out the Master Clinical Forms from Documentation Wizard   ^TM . This Assessment contains all the information you need to determine prognosis, so you can be confident that your documentation meets all Medicare and insurance requirements.

Beth Rontal, LICSW, the “Documentation Wizard”, has been teaching the skills of clinical documentation since 2012. She loves empowering clinicians to master the documentation process so they pass audits, protect themselves from legal nightmares, and reduce their anxiety. She also has an active private practice, is writing a play, and loves to sing. Do you have more questions about clinical documentation? You can become a Documentation Wizard, too! Check out Beth’s online workshop, Misery or Mastery:  Documenting Medical Necessity, and learn how to how to translate the work you already do into the behavioral language required by insurance companies.