Mental Health Documentation for Worker’s Compensation

A therapist recently asked me how to document for a Worker’s Compensation claim. 

Some companies will accept a summary of treatment.  Most will want the client’s full record.  That will include the Diagnostic Assessment, Treatment Plan, Progress Notes, and any Collateral Contact Notes. If this is the case, documenting for Workman’s Comp is no different than what I recommend for mental health documentation in general. There are a few points to keep in mind:

• Use a mental health diagnosis even when the client’s presenting problem is about dealing with what happened at work and not about mental health issues.
• Treatment is short-term and the goals need to reflect that.
• Make sure to include the goals, objectives, interventions, and progress.  Workman’s Comp needs to see progress just like the insurance companies.
• Have a plan for returning to work.

USE A MENTAL HEALTH DIAGNOSIS

This sounds too simple to even say but you must use a mental health diagnosis to prove impairment. This may pose a problem because some people don’t have enough symptoms that qualify them for a full-blown anxiety or depression diagnosis, PTSD, or any other mental health issue. But if they are seeking Workman’s Compensation, it’s because they’re struggling as a result of something that happened at work. So, consider diagnosing them with a severe Adjustment Disorder or Acute Stress Disorder.  

Whatever you diagnose them with, make sure you document that the symptoms started as a result of the incident that triggered the claim.

Ronald’s work-related incident triggered anxiety, which resulted in sweaty palms, racing thoughts, shortness of breath, nightmares, flashbacks, disordered sleep, hypervigilance, and avoidance of the trigger.  The symptoms started after he was attacked at work and were present for about one month before he sought treatment. He reported no significant prior trauma history or debilitating symptoms, and that he was highly functional prior to being attacked.  Ronald sought therapy four months after he was attacked and wisely sought treatment before the symptoms took complete hold of his biochemistry. He therefore didn’t meet the criteria for PTSD.  Ronald is diagnosed with Acute Stress Disorder.

DOCUMENT HOW THE SYMPTOMS RELATE TO THE WORKER’S COMPENSATION CLAIM

Make sure you document that the symptoms started as a result of the incident that triggered the claim. If there was prior trauma that got stirred up, document that the symptoms got worse after the incident. Keep in mind that you can’t bill the Workman’s Comp company for treating prior issues. Therapeutic goals for Workman’s claims are achieved when the client reaches “baseline” or pre-incident functioning.

Use behavioral language.

Writing the symptoms in your treatment plan is not enough.

• What happens when the client has flashbacks? Ronald dreaded talking about the incident because it created flashbacks. So, he didn’t talk about it.
• What does the hypervigilance cause the client to do or not do? Ronald checked the locks on his front door multiple time before going to bed and then again in the middle of the night, every night.
• How often does the client have nightmares? Ronald had nightly nightmares. They made him afraid to go to sleep and woke him in the middle of the night causing extreme fatigue during the day.
• Besides nightmares, how else is the client’s sleep disrupted? Does he wake often or have a difficult time falling asleep or both? And how often?  Ronald could fall asleep but woke easily several times each night (to check door locks) and had a difficult time falling back asleep every time he woke up, every night.
• What does the client avoid?  Ronald could not go to the building where he worked without breaking out in a cold sweat. So, he avoided going anywhere near where he worked.  He also avoided public speaking, which was part of his job. Every time he tried to speak in front of a group, he “choked.”

In order the for symptoms to decrease, these behaviors needed to change. 

Have clear goals that relate to the worker’s compensation issue.

Your client may bring in other issues.  Keep the treatment focused on the issues covered by Worker’s Comp. Keeping this focus can be difficult, but it’s essential for coverage. And it keeps treatment highly focused and short-term.

If the client brings in other issues, which could happen with someone who’s had previous trauma, explain how the previous problem contributes to the severity of the current one. But be prepared to have the company insist that past issues are not part of the current treatment.  

Ronald’s goals were very clear:

• Eliminate nightmares, obsessive checking, and daily fatigue.
• Sleep through the night peacefully.
• Be able to talk about the attack with coworkers, without dread or flashbacks.
• Be able to talk about the incident with others calmly and to set clear boundaries about what he would talk about.
• Be able to go to the office without breaking out in a cold sweat. 
• Be able to perform his job of public speaking without “choking up”.

Have a plan to return to work.

The Worker’s Comp company wants to know that treatment is time limited and the client plans on returning to work. If the consequences of the triggering event are so severe that the client cannot return to work, you will need to document that in the progress note. But your plan needs to include the goal of returning to work.

It took three sessions to learn what happened to Ronald.  Even though more came out during subsequent sessions, Ronald felt he fulfilled one of the goals. By the third session, he was able to talk about the incident without breaking into a cold sweat.  We did mind/body work and exposure therapy.  As we addressed the problems and reduced some of the symptoms, we staged his return to work.  First, he would go to the office accompanied by a close friend. Then he would sit in on a meeting. Then he would go to work for 2 days a week. Then 4. Then 5. We discussed and processed each aspect of his treatment and documented it. Once we determined the plan, we documented each step in the progress notes. 

Document progress!

No matter how little, make sure you notice and document the progress the client is making in each note and treatment plan. If progress is particularly slow, explain why. If there is consistently “no progress,” the Worker’s Comp company can decide that the client has reached the highest level of functioning and terminate coverage. You want to avoid this scenario!

Because Ronald had no prior history of trauma, he made steady progress.  As we worked though the trauma, nightmares got less frequent and eventually stopped. After the first month, he stopped waking to check the front door. With more rest, he was able to go to the gym and regain strength he’d lost as a result of injuries he sustained. We planned exposure work, the number of trips to the office, how long he would stay and if he wanted coworkers to meet him there.  And so it went until he could go to work by himself and speak in public without anxiety!

Project an end date to treatment and work towards it.

This is one of the hardest things for a clinician to do because we don’t have a crystal ball. But it must be done. Worker’s Comp is short term work. They will not pay for long term care. If the client needs therapy after the Worker’s Comp therapy has been fulfilled, the bill will need to transfer to the client’s insurance company, or the client will need to pay out of pocket.

Because Ronald did not report prior trauma, I estimated that he would finish treatment in six to nine months. He was ready to return to work in seven months!

Had we needed more time, I would have documented why.  

Ronald had a lot going for him.  A very spiritual man, he drew on his relationship with god, his spiritual community, and his husband. He forgave his attacker.  His attacker moved across the country so there was no chance of accidentally meeting.  Because Ronald was able to be explicit about his needs, his coworkers honored his need for boundaries. They did not ask him to describe how he felt.  

The Worker’s Comp company requested my documentation every month. Because I knew how to document to the justify his treatment, I had no worries about sending my notes. This meant I didn’t need to spend time writing a separate review of treatment.

What I didn’t mention earlier is that I was able to charge – and get paid my full fee.  The extra work of printing out and sending my notes was worth the effort.

One last thing about Worker’s Compensation.  I think the name should be changed to Worker’s Comp!

If you are unsure about what and how much to write and how to write for Worker’s Comp or mental health documentation in general, check out my course, Misery or Mastery: Documenting Medical Necessity for Psychotherapists.