Whatthe insurance companies want.
Discussionby Dunlap & McDowell for 2-28-03 Pragmatics of HIPAA Training
Reviewingthe conflicts between what most mental health professionals consider to bepsychotherapy notes and what HIPAA defines as psychotherapy notes. (see TherapyNotes vs Clinical Record and The Contentious Matter of PsychotherapyNotes,) mental health professionals realize that this area is where we mustdraw clear boundaries in protecting client privacy.
Thedocument in the box below illustrates the position taken by insurance companiesconcerning how psychotherapy sessions should be documented, with the clearimplication that such documentation would be available for review by theinsurance company.
Notehow far these requirements exceed even HIPAA requirements for documentation.Refer to the Guidelines Documents issued by the American PsychiatricAssociation. (Linksbelow)
Guidelines for Clinical Documentation of Therapy Sessions
Clinical notes for outpatient and inpatient therapy sessions serve to document not only the patient's clinical status and progress, but also serve to ensure that quality of care is adequate and payment is made for services provided. The record should include documentation that each therapy session was an active, directed process and that the therapist regularly took stock of specific clinically valid treatment issues. Clinical notes do not need to be lengthy. At a minimum, clinical notes should include:
• Date and length of therapy sessions
• Patient's current clinical status as it relates to diagnosis and as evidence by the mental status and physical status observations
• Clinically important objective events in the treatment setting or the patient's life (e.g., the therapists unexpected absence, or a death in the family)
• Documentation of practitioner/provider's efforts to obtain relevant information from other sources
• Collaboration with other practitioner/providers and providers
• Content of the therapy session (i.e., major themes discussed)
• Summary of the therapeutic intervention of the session
• Summary of an assessment of the patient's progress or lack of progress toward the treatment goals. Changes in diagnosis, DSM or ICD codes, functional status, etc. (e.g., the appearance of new symptoms, return to work, new medication)
• Treatment plan for the immediate future, and
• Medications (if any) being prescribed by the practitioner/provider, such as the name, dosage, instructions and any side effects that have occurred. The record should document as appropriate that noted positive benefits outweigh noted side effects.
• Notation that the patient has been fully informed and indicated an understanding of the risks and benefits of a new medication or therapeutic procedure
Group, conjoint and family therapy
Clinical notes are required for each group, conjoint or family therapy session. Again, the notes need not be lengthy. The clinical notes should include:
• Date and length of therapy sessions
• Number of participants
• Relationship of the participants to the patient if it is conjoint or family therapy
• Content of the therapy sessions (i.e., major themes discussed)
• Summary of the therapeutic intervention attempted during the therapy session
• Summary of how the session has influenced the patient (or relevant significant others) as compared with the treatment goals, and
• Nature and degree of the patient's participation and response to the therapy session
From the Regence BlueCross/BlueShield of Oregon "Behavioral Health BluePrint" (Nov. 2001) and the draft American Psychiatric Association "Resource Document on Documentation of Psychotherapy, October 8-9, 2001
Notethat this “guideline” exceeds even HIPAA documentation criteria substantially, and that it misrepresents the tone and concerns of the AmericanPsychiatric Association Documents to which it refers.