Trainings

The Problem

Clinical Documentation has always been integral to the professional standard of care. Yet many psychotherapists are unsure how to document the good work they provide. As a result, they can feel at the mercy of insurance companies, spending an enormous amount of time justifying treatment, fighting rejected insurance claims, fearing or preparing for audits, writing disability reports and losing income. Clinicians both in private practice and those working in agencies and group practices, as well as clinic owners and managers report there is little guidance about what to write while clinicians find that there is little time to write it.  Paperwork often seems unrelated to being helpful to the client.  Confusion over third-party expectations and often substandard paperwork is a common result, leaving both clinician and clinic vulnerable to a financial loss if records are audited, or to legal, ethical or professional issues if records are subpoenaed.

The Goal

With the growing concerns about addiction, child safety, family violence, legal issues, and the corresponding rise in oversight, whether from insurance companies, the department of social services, workman’s compensation, or the courts, the more important good record keeping has become. Additionally, because the courts can mandate access to records, understanding issues of confidentiality and privacy in relationship to documentation requirements are critical.

Good documentation skills should help organize clinical thinking. Progress notes, treatment plans, case and collateral contact notes, discharge and diagnostic summaries should be able to be done quickly and efficiently and provide a vehicle for formulating and reflecting on high quality clinical work rather than being a detour or afterthought. Good documentation supports good clinical practice, facilitates getting authorizations, and helps mental health professionals and clinics pass insurance audits, thus saving thousands of dollars in potential recoupments and lost productivity. It contributes to a marked reduction in work related anxiety and increased job satisfaction.

The Standards

Since psychotherapy is covered by medical insurance, the gold standard for documentation is now based on the need to satisfy insurance company requirements. The most rigorous standards for clinical documentation are Federal, which is why most third-party payors base their requirements on Medicare standards.

That standard is conceptualized as “medical necessity.” A fundamental feature of medical necessity is, the “Golden Thread.” When the Golden Thread is employed, each element of the therapeutic process is clearly documented so that the connection between all aspects of clinical work flows logically from one record to the other. In-other-words, the criteria for a client needing services and the Golden Thread work together to justify medical necessity. At the same time, it is important that the clinician’s voice be heard in a narrative so that it is clear how they conceptualize the treatment rather than relying solely on a template with boiler plate drop down menus for all aspects of the record. This includes effectively documenting clinical progress while maintaining confidentiality. When clinical documentation is operationalized using this effective, efficient, and distinct procedure, medical records are clear, compliant and clinically useful. Documentation is necessary even for those psychotherapists who do not take insurance but still wish to meet professional, legal and ethical standards.

The Result

Applying the Documentation Wizard  process to whatever system is used, increases accuracy and efficiency. It simultaneously reduces anxiety and resistance and contributes to quality care. The concepts and practice of this system are taught to Medicare standards and have a proven track record of success. Implementation of this system helps pass stringent Medicare audits, potentially saving clinics and clinicians thousands of dollars. Additionally, a reduction of time spent writing and rewriting paperwork, coupled with a significant increase in productivity and profits can lead to greater job satisfaction and less burnout. Choose mastery over misery and allow good clinical documentation to be a contribution to high quality care rather and protect your practice at the same time.