Questions & Answers: Treatment Plans
Trying to figure out everything you need to know about clinical documentation can make your head spin! The good news is, I’m here to help! In this month’s blog post I answer some of the most commonly asked questions about treatment plans.
QUESTION 1: Primary, Secondary, & Tertiary Diagnoses
I’m looking at the Treatment Plan examples that came when I purchased the Clinical Forms package. It has two problem areas in the plan (primary/secondary) with no space for tertiary, if there is a tertiary diagnosis. Is this acceptable for disability and insurances to only list the primary/secondary and not the tertiary in the treatment plan?
It depends on how you conceptualize the case and how much the third diagnosis affects the functioning and prognosis of the client. If you need to add a third diagnosis, it’s pretty easy to add it to Documentation Wizard’s templates. Using the Word Doc template, you can copy and paste a 3rd problem area after Problem Area 2. Space for a 3rd problem area already exists in the fillable PDF. For more information, visit https://documentationwizard.com/master-forms/#clinical.
QUESTION 2: Writing a New TX Plan vs. Updating TX Plan
I wrote a treatment plan for May 2021 to May 2022 with GAD for the diagnosis. Client discloses substance abuse for the very first time in January 2022. Do I make a new treatment plan for substance abuse now and if so, what dates? Do I keep the same dates but now add substance abuse and new goals? What steps do I need to take to do the treatment plan correctly?
There are no hard and fast rules about when and how to change the treatment plan before the due date. But the revealing of substance abuse is good cause to do so. To limit the amount of work, I might keep the same dates on the plan, add in the information about substance abuse and indicate when the substance abuse was discovered. This way, you can be consistent with the date of the plans and when you update them. With this kind of problem, just make a decision, have a reason for it, and document it. Then be consistent when other issues like this come up.
QUESTION 3: Documenting Progress
I’m new to the field and confused about the progress section of treatment plans. How often should this section of the treatment plan be updated to reflect progress?
First, it’s important to know how often to write a treatment plan. Generally speaking, commercial insurance companies expect private practice therapists to write a yearly treatment plan. Medicare and Medicaid expect them every 3 months. However, it’s sometimes possible to negotiate a 6-month review period or even once per year if you provide the reason*.
*Example: “My clients present with severe symptoms and complex bio/psycho/social stressors. Treatment is expected to last several years. Prognosis is good because progress is slow but steady. Most goals will not change substantially in a 3 or 6 month period of time. Writing a yearly treatment plan will provide the most obvious examples of change.”
Request 6 to 12 months review periods from each insurance company you work with. Remember to document the slightest amount of progress in each session note unless the client relapsed. Then document the yearly progress in the treatment plan. This way, you reinforce your clinical judgement that progress is slow but steady.
PS. One therapist I consulted with regarding a 4-year retrospective Medicare audit submitted yearly treatment plans without getting prior approval. She just submitted them — and passed 100%. But it’s better to be safe than sorry so get approval from each insurance company and then document the phone call or email.
QUESTION 4: Required Components of a Treatment Plan
My practice management system isn’t set up to document specific target dates and the other elements of a treatment plan you recommend. Are Problems, Goals, Interventions, Target Dates with Modality, and a review target date required? Or are there other things that commercial insurance and Medicare require?
Let’s start with the question of “review dates.”
Are review dates mandatory? No but they should be. One of the issues I have with many practice management systems is the omission of treatment plan review dates. Review dates are extremely important. Otherwise, you don’t know the time frame involved in assessing progress and when it’s time to write the treatment plan review, which is required. (See question #3 for frequency.) The lack of review dates can cause confusion about when to write treatment plans, omissions in the clinical record if overlooked, and lack of progress documented. So though review dates are not “required,” they’re best practice.
Documenting the problem is required. Without the problem, there are no goals. But let’s get clear about the difference between the “problem” and the “symptoms” because they are often conflated but not the same. The symptoms are a list of criteria to justify the diagnosis. The “problem” describes how the symptoms effect the client or the client’s behavior. The behaviors show what the symptoms cause the client to do or not do. Change is measured by changes in the client’s behavior. Everyone wants to know if and when change is happening; the therapist, the client, and the insurance company. Once you know the behaviors that need to be changed, you can determine goals. Documenting behavior means you are treating a person, not a diagnosis. Not only do insurance companies want to know we’re treating a person and not a diagnosis, this method of documentation makes clinical sense.
Goals are also required. What are the behaviors the client is going to change? One of my pet peeves is that many practice management systems jump from the diagnosis to the goals. But as described above, there are no clinically relevant goals without a problem specific to the client.
Yes, interventions are required. We need to document what the therapist does to do to help the client reach the goals. Enough said.
Target dates depend on the length of time between treatment plans. If you write a plan every 3 months, meaning short-term goals, then specific dates (meaning within 2 weeks/by 3 months, etc.) is necessary. I write treatment plans for long term goals. So I’m able to track the dates of change in the progress of each session note and at the year review.
Documenting the therapy technique is not required but it’s a good idea. However, it can also be tricky for both new and seasoned clinicians.
New clinicians are often not trained in specific modalities so can’t name them. For clinicians new to practice, it’s OK to use “insight oriented.” Insight does not guarantee change but most change doesn’t happen without insight. CBT is also a reliable modality because it’s all about changing behavior.
Seasoned clinicians may have multiple modalities they’ve been trained in, which causes a different problem. So at ease with mingling modalities, that they may not be sure what modality they are using. Or they may be combing them. It’s OK to indicate the use of multiple modalities.
I hope this helps clarify some of your questions about writing treatment plans. Once you really understand how the problem, goals, interventions, progress, and frequency work together, it becomes easy and actually has a positive impact on your clinical work. If you want more information, consider taking my online course, Misery or Mastery: Documenting Medical Necessity for Psychotherapists.
Become an Expert at Writing Treatment Plans!
Treatment plans and so much more are explained in my online training, Misery or Mastery: Documenting Medical Necessity. It teaches you a step-by-step approach to guide you through the process of writing treatment plans, session notes, and the other essential clinical documents needed in every clinical practice. Visit https://documentationwizard.com/online-workshop/ to get started.
BarbaraJean Keane says
1. Can the actual completed “Session Note” form be submitted to Insurance Companies if Medical Record is audited? Is the form itself the actual progress note?
2. Is there a way to printout forms and then complete. When printed out there wasn’t enough room to write everything.
BTW, I am far from a Documentation Wizard or Tech Wizard:)
Beth Rontal says
Thanks for asking, Barbara Jean.
Most therapists are not Documentation Wizards. You don’t even have to be. You just need to be competent. You weren’t taught the skill in school or during your internships but you can still learn. Keep asking questions and keep breathing. Now for the answers to your questions…
1. Yes, the Session Note template you purchased from Documentation Wizard, is the medical record and what you send to the insurance company if audited. You might be confused about this because some people call the note, a Progress Note. I prefer to call it a Session Note because I provide “a session,” not “a progress.”
2. If you like to handwrite your notes, print out the fill-able PDF. You received it when you purchased your clinical forms. It’s designed to fit on 2 pages so there is room to write. It’s all explained on the website. https://documentationwizard.com/product/clinical-forms/
All my best, Beth
The group I work for uses the electronic program Therapy Notes. Now that I have purchased your templates, I was wondering how to incorporate it into the TN template? Specifically, they have narrative sections for Symptom description and subjective report, and for Objective Content. I wondered if you might say which of your sections fit into these two broad sections.
I see you have Symptoms and Client reports (quote) boxes, and I wondered what else, if anything you might add to the TN narrative section? I wasn’t sure what you would put in “Objective Content”
Beth Rontal says
Good questions, Kim. As with almost everything concerning psychotherapy, though the question is “simple” the response is not necessarily a simple one. It brings up other questions. It’s best to schedule a consultation so you can get all your questions answered in a way that truly helps you streamline your documentation.