Should I Document Medications on Progress Notes?
QUESTION: Should I Document Medications on Progress Notes?
I have heard from others, who consider themselves Medicare documentation experts, that it is unnecessary to document anything about psychiatric medication compliance and effectiveness. They advise against it as it is the prescriber’s job, not the psychotherapist’s job. Should I document medications on progress notes?
ANSWER
With all due respect, I disagree with those who say that monitoring meds is out of our scope of treatment. One would think that the reasons why would be simple, but, as is common in mental health care, the reasons are nuanced.
Though documenting medications on the Diagnostic Assessment (Intake Assessment/Bio-Psycho-Social Assessment), is mandatory, documenting medications and medication concerns in each session note is not “mandatory.” However, it is best practice. Checking on our clients’ medications is not out of our scope of treatment as mental health therapists. Therapists typically see clients more often than prescribers. We are therefore more poised to spot a potential medication issue faster than during a psychiatric checkup that happens every 3 months – if that often. We monitor for possible side effects, compliance, changes in mental status that may be a result of psych meds, and more. Based on our monitoring, we may recommend our client gets a med check. As a professional standard of care, we are required to communicate our concerns to the prescriber as a collateral contact. Doing so is quality care.
I provided consultation to a therapist who was audited on a client he’d been seeing for 20 years. Though considered one of the “walking wounded,” this client needed continued therapy to stay functional. With therapy and meds, the client was highly functional. Without – the client decompensated. The insurance company insisted that the therapist track the client’s response to the medications for 3 months before agreeing to authorize continued treatment for the rest of the year. Having the name, dosage, and frequency on each session note facilitated the monitoring of the client’s response to the meds. Having this information on each session note is a cue to the therapist to ask about medications — and document any changes on the day the information comes to light. The Documentation Wizard Clinical Forms, developed to meet all Medicare standards, have a prompt for this on the session note (and the Diagnostic Summary and Treatment Plan).
In particular, when working with elders and kids, who are most sensitive to even the slightest medication and medication changes, we are particularly obliged to know and check in on medication compliance and potential side-effects. It could save their lives. It could also save you from a legal nightmare if something is amiss and you catch it.
I highly respect the other experts on documentation. I’ve taken their trainings and I know what’s on their forms. Though I understand that other documentation experts believe that we don’t need to document medications, because medications are out of our scope of treatment, I disagree. We are not stepping on the prescriber’s toes. We’re gathering information to recommend that the client get a check-up and/or information to write a collateral contact note to the prescriber or call the prescriber and express our concerns.
It’s important to report to the insurance company that we’re attentive to all aspects of the client’s mental health care. It can save both lives and our licenses. Thorough documentation not only protects us from legal issues, it improves our clinical skills and contributes to high quality care. For the clinical forms that cue you to document all requirements (to Medicare standards), checkout the Documentation Wizard Clinical Forms.
Document What Matters. Leave Out What Doesn’t.
Progress notes are not medication logs. They are clinical documents. Our Clinical Forms Package helps you collect and document medication information in a way that supports diagnosis, functional impairment, and medical necessity without unnecessary detail.
Beth Rontal, LICSW, a private practice therapist and the Documentation Wizard® is a nationally recognized consultant on mental health documentation. Her Misery and Mastery® trainings and accompanying forms (in English and Spanish) 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 2 attorneys, a bioethicist, and a billing expert 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. Her newest initiative, Membership Circle, is designed to empower psychotherapists to master documentation with expert guidance, efficient strategies, and a supportive community.
