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F- Progress Notes and Psychotherapy Notes This Appendix covers two kinds of notes written about psychotherapy—progress notes and psychotherapy notes—and highlights the practical value of this important distinction. Progress notes are part of the client record or file, as noted below. Psychotherapy notes are not part of the file. After an overview of the client file or record, the difference between these two kinds of notes is discussed along with guides for writing progress notes. The Client File or Record The record or file of a client’s treatment at the Clinic consists of: Contact information Informed consent for treatment (including notification of rights) An intake report and/or, A written treatment plan or case formulation based on an initial assessment (i.e. interview information, formal assessment if used, and any other information collected from other sources) Progress notes documenting treatment, filed in reverse chronological order on the Clinic form Progress Note A termination note when work is concluded Other materials such as releases of information, test protocols, information obtained from other sources and so forth. The file or record does not contain psychotherapy notes (see below). Another way of saying this is that if it’s in the file, it’s not a psychotherapy note. As context for progress notes versus psychotherapy notes, please also refer to the form in Appendix D Brief Summary of Client Rights to Privacy and Access to Records and Consent to Behavioral Health Treatment and to the document in that appendix entitled Protecting the Privacy of Your Behavioral Health Information. A general intake outline is contained in Appendix C-4 Intake Outline and Report which can serve to organize information and begin treatment planning. Treatment planning will, to some degree vary by supervisor and may be organized around a diagnosis, a problem list, a set of treatment goals or a listing of directions for therapy. Therapy notes (either progress notes or psychotherapy notes) may be easier to write and later to interpret if written toward a good treatment plan. Progress Notes versus Psychotherapy Notes: A Key Distinction. Psychotherapy notes. Over the years, clinicians have debated about whether it was permissible to maintain a second set of notes which was not available to anyone except the therapist. One of the few substantive changes brought about by HIPAA is that psychotherapy notes are defined and are protected from normal release to the client, the courts or anyone else. This distinction is sufficiently important that the clinician should be familiar with the language of the federal regulation: Psychotherapy notes means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. 45 CFR 164.501. A later section (45 CFR 164.524) gives individuals almost unlimited access to their records, but specifically excludes psychotherapy notes as defined above. The key elements of this definition and its use are that psychotherapy notes: Are produced by a mental health professional Are separated from the rest of the medical record Don’t include the basic treatment and record-keeping that goes in a standard progress note, and Are not open to disclosure to the client or anyone else.
F- Progress notes. Progress notes, then, are notes that are part of the regular file maintained in the Clinic. Because many of the functions of notes for the purposes of the treating clinician can be accomplished through psychotherapy notes, progress notes content can be kept to minimum. The following kinds of information go in a progress note (further guidelines and examples appear below). counseling session start and stop times, medication prescription and monitoring the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: o Diagnosis, o functional status, o symptoms, o prognosis, and o progress to date. Who Is The Audience? In any writing project, the first and most important question is “who is the audience?” Throughout the writing process, one must step back occasionally and hear what is written using the ears of the potential audience(s). Often, as with the notes we’ll be discussing here, there will be multiple audiences and you must keep each of them in mind while writing. Here is a listing, intended to be in order of likelihood, of those who will see and use progress notes: You, the therapist, will look back at the notes as needed in the course of treatment. The client or patient may want to look at the notes and the contents of the file and has this right under New Mexico guidelines and HIPAA regulations Another therapist who picks up the case at the Clinic or in another setting (with appropriate release of information). An evaluator for another agency may review therapy notes, again with the client’s permission An attorney representing your client or (perhaps more importantly) an opposing attorney in a legal proceeding (this may be by release of information or through a “hidden permission” in a law suit claiming damages for “pain and suffering”—see the Clinic’s document Protecting the Privacy of Your Behavioral Health Information). These various potential readers of your notes create different concerns and expectations for the contents of your notes. What will be most useful to you in the future may very well not be what you would want your client to read and a note that works for you and your client may not be something you’d want in the hands of a attorney hostile to your client’s interests. You won’t know as you write which audience will see your notes, but need to keep in mind that you are writing for these different readers. This is not, in practice a difficult task. First, keep in mind that your task in a progress note is to document that reasonable work occurred toward the goal of helping the client with her or his issues. Your note can be brief; to the extent that you can relate that day’s work to treatment issues and methods you’ve defined previously in a treatment plan, the easier your documentation will be. Keep track of significant events—changes in medications, life events, names of important people that come up—that you will want to be able to easily reference in the future. As noted in the formats described below, include brief assessments of the client’s status and progress as appropriate and remind yourself of plans you have for future sessions (homework assignments, topics to follow up on). Leave longer thoughts, queries and reflections for your psychotherapy notes. The advantage that psychotherapy notes give us is that you can record any hypotheses, personal reactions, doubts, possible interpretations, supervisory recommendations, etc. in a form that will be maximally useful for you. Where Are The Two Kinds Of Notes Kept? In general, progress notes will be written immediately following a session and will be kept in reverse chronological order in the client’s file locked in the appropriate drawer in the Clinic. The client’s file may be removed only for purposes of writing and reviewing notes and replaced when you are finished. Supervisors will
F- assessment of danger or legal issues, you would document what you did in whatever detail is necessary to show that you attended to the issues involved. Assessment is your understanding of what the event means if you know. Baird recommends thinking about how the event or behavior relates to precipitating factors, to previous behavior, to other events in the client’s life, to the treatment plan. The important part of this aspect of your thinking and writing is your reflection on the events in the client’s life in terms of treatment. Assessment may also record your observations about the client’s physical or emotional state and such factors as severity of symptoms, riskiness of behavior, dangerousness, suicidality and so forth . Treatment Plan is your plan for future treatment. Baird notes that this may be as brief as “Scheduled for next Wed”. If you give homework assignments or want to note topics to follow up on or actions to take before the next session, they can be entered here as reminders. Examples of DAP notes are given on the Clinic website. SOAP format notes. SOAP is an acronym for Subjective-Objective-Assessment-Plan and is a part of Problem Oriented medical records developed by L. L. Weed (see Cameron and Turtle-song, 2002 on the Clinic webpage for a fuller description). This method was developed in the medical setting to standardize entries in the patient file (e.g. S(ubjective): “Patient complained of …”; O(bjective): Blood pressure, lab results, results of physical examination; A(ssessment): clinical diagnosis of symptoms; P(lan): prescriptions, treatments recommended, etc.). In psychology practice, Assessment and [Treatment] Plan are similar to what Baird describes. The SOAP format is widely used especially in hospital settings and is required in some agencies for psychological and psychiatric progress notes as well as medical notes. But some have noted (e.g. Baird, 2004) that the format it may become arbitrary or rigid, for instance, what material goes in which section. It is especially difficult in psychotherapy to sort out what is objective and what is subjective and the meaning of events may be lost. Student-clinicians may find this format useful, however, and examples are given on the Clinic website. Unformatted notes. Clinicians may write notes in a less or differently structured fashion, such as integrating Baird’s sections in a narrative form, providing a chronological sequence of events in a session (process notes) or referring notes to specific issues in the treatment plan. The above discussion, and additional reflection on one’s own treatment approach, may stimulate the student to develop their own format for notes that better suit their method and style. Students are encouraged to discuss with their supervisor approaches to progress notes. Psychotherapy Notes: Reprise The greater protection provided to psychotherapy notes by HIPAA regulations may allow student-clinicians greater latitude to abbreviate their progress notes and expand on the reflection, reactions, thoughts and feelings that may safely be recorded in psychotherapy notes. To return to an earlier theme, the primary audience for psychotherapy notes is yourself: your client acknowledges in the Clinic’s consent for treatment that such notes may be kept and are not available for client inspections. This allows you greater freedom to reflect on difficulties, hunches and questions and make these written reflections a greater learning experience in the context of your supervision. Suggested Readings Baird, B. N. (2004) The Internship, Practicum, and Field Placement Handbook: A Guide for the Helping Professions (4th^ ed.). Prentice Hall Cameron, S. & turtle-song, i. (2002) Learning to write case notes using the SOAP format. Journal of Counseling & Development, 80 , 286-292. Wiger, Donald E. (1999) The Clinical Documentation Sourcebook: A Comprehensive Collection of Mental Health Practice Forms, Handouts, and Records (2nd^ ed.). Wiley. Zuckerman, E. L. (2005) Clinician's Thesaurus: The Guide to Conducting Interviews and Writing Psychological Reports (6th^ ed.). Guilford Press.
Psychotherapy Progress Note Psychiatric Social Worker Date of Exam: 4/28/ Time of Exam: 9:00:56 AM Patient Name: Conner, Andrea Patient Number: 1000010644560 Improvement is occurring. "My social life now revolves around exercise instead of drinking with my friends." Problem Pertinent Review of Symptoms: Feelings of anxiety are denied. Andrea denies experiencing dysphoric moods. Sleep disturbance is not reported. Andrea describes rare substance cravings. She denies the temptation to use. Andrea denies use. Andrea reports that she has been regularly attending AA meetings. A sample for urine drug screening was obtained. She has maintained sobriety. Impulsive behaviors are not reported. Content of Therapy: The patient's substance abuse problems were the main issue this session. Feelings of shame were also expressed. Therapeutic Interventions : The focus of today's session was on helping the patient increase insight and understanding. The main therapeutic techniques used involved the exploration of the patterns of certain behaviors. Therapeutic efforts also included aiding the patient in identifying the precipitants of unproductive feelings and behaviors.. The importance of abstinence was also reviewed. MENTAL STATUS : Andrea is alert, attentive, casually groomed, and relaxed. She exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Mood is entirely normal with no signs of depression or mood elevation. Affect is appropriate, full range, and congruent with mood. Insight into illness is normal. Social judgment is intact. Signs of chemical withdrawal are exhibited by Andrea. Mild signs of anxiety which appear to be secondary to withdrawal are present. DIAGNOSES : The following Diagnoses are based on currently available information and may change as additional information becomes available. Axis I: Alcohol Abuse, 305.00 (Active) INSTRUCTIONS / RECOMMENDATIONS / PLAN: Link to Treatment Plan Problem: Substance Abuse Short Term Goals: Andrea will make plans for a recreation activity that does not involve alcohol or drugs, within one week. Target Date: 4/29/
Excellent progress in reaching these goals and resolving problems seemed evident today. Recommend that the interventions and short term goals for this problem be re-written at the next Treatment Team meeting.
Return 2 weeks or earlier if needed. NOTES & RISK FACTORS: History of Subst. Abuse 90806 PSYTX, Office, 45-50 MIN Time spent counseling and coordinating care: 45-50 min Session start: 9:00 AM Session end: 9:50 AM John Smith, LCSW Electronically Signed By: John Smith, LCSW On: 4/22/2012 11:07 AM
INTAKE ASSESSMENT (EXAMPLE)
Patient: Date of Birth: Intake Date: Presenting Problem(s): _______________________________________________
Presenting Symptoms: _______________________________________________
Presenting Problem History: ___________________________________________
Family History: ______________________________________________________
Education and Occupational History: ____________________________________
Medical Problems: ___________________________________________________ Current Prescription Medications: Name: ________________________________ Dosage: _______________________________ Estimated Start Date: ____________________ Alcohol, Nicotine, and Drug History: _____________________________________
Mental Health Treatment History (Patient & Family): _______________________ Legal History: _______________________________________________________
Spiritual Life: _______________________________________________________ Exercise: ___________________________________________________________ Mental Status: ______________________________________________________ (This should provide a basis for understanding the patient’s presentation)______ a. Appearance b. Manner and Approach c. Orientation, Alertness and Thought Processes d. Mood & Affect (Including suicidal and/or homicidal ideation Summary and Conclusions: ____________________________________________
Treatment Recommendations and Prognosis:______________________________ Diagnoses: Axis I: _____________________________________________________________ Axis II: ____________________________________________________________ Axis III: ____________________________________________________________ Axis IV: ____________________________________________________________ Axis V: ____________________________________________________________ Current ___________ High Previous Year____________________ Signature and License
PROGRESS NOTES (EXAMPLE)
Patient: Date: Start & Stop Time: Treatment Modality: _________________________________________________ Problems Addressed:
Progress:
Suicidal & Homicidal Ideation:
Scheduled Appointment: ______________________________________________ Signature and License
PSYCHOTHERAPY NOTES
Psychotherapy notes are treated differently than other medical records. Psychotherapy notes, according to HIPAA, are protected from normal release to the patient, the courts or anyone else, unless stipulated by state law. The key elements of psychotherapy notes are: They are produced by a mental health profession They are separated from the rest of the medical record They don’ t include the basic treatment and record‐keeping that goes in a standard progress note By their nature, psychotherapy notes can be in any form that the therapist wants. They can be used to detail what happened in a session. They can be reviewed to produce hunches and hypothesis and help direct therapy. Issues can be detailed that the therapist would want to keep private.
APPLESEED COMMUNITY MENTAL HEALTH CENTER, INC. COUNSELING PROGRESS NOTE Rev 03/2010 ACMHC COUNSELING PROGRESS NOTE Page 1 of 1 Client Name (First, MI, Last) Betty Borderline Client No. 5.0.5. Others Present at Session: If others present, please list name(s) and relationship(s) to the client: Client Present Client No Show/Cancelled Stressor(s)/ Significant Changes in Client’s Condition (for face-to-face visit) No Significant Change from Last Visit Mood/Affect Thought Process/Orientation Behavior/Functioning Substance Use Danger to: None Self Others Property Ideation^ Plan^ Intent^ Attempt^ Other: Goal(s)/Objective(s): G oal 1/objective 1 Therapeutic Intervention and Progress Toward Goal/s: Client reported she had strong thoughts of self-harm this week but had not acted on them. I asked how she had done this and labeled the skills she had used to assist her in circumventing these thoughts. Affirmed validated her feelings noting she had done this without the people who usually are available to help her get through these difficult times. Discussed the reason for thoughts of self-harm to increase awareness of when thoughts could re-occur in order to plan to effectively manage these thoughts. Client commended for gaining the ego-strength to counteract urges to harm herself. Client recognized her dysfunctional thoughts were, in part, the result of a disrupted routine that created anxiety which triggered self- injurious thoughts. Client states that she does not currently have thoughts of self – harm. Recommendation for Modification and Update of the ISP if Applicable: NA Provider Signature/Credentials Thomas Therapist, LPC Date 12/23/ Supervisor Signature/Credentials (if needed) Date Medicare “Incident to” Services Only Supervisor Signature/Credentials (if needed) Date Supervisor Consultation (if needed) Date of Service Staff ID No. Loc. Code Prcdr. Code Mod 1 Mod 2 Mod 3 Mod 4 Start Time Stop Time Total Time Diagnostic Code 12/23/10 007 11 15 HE - - - 1:00 - :60 301.
BELLEFAIRE JCB OUTPATIENT TRAUMA FOCUS COGNITIVE BEHAVIORAL THERAPY (TFCBT) PROGRESS NOTE CASE TYPE: WRAP TFCBT; JOP/WRAP TFCBT; OUTPATIENT TFCBT; SCHOOL BASED TFCBT Client Name: (Last, First) Client #: Date of service: Staff ID, Name : Client Start Time (^) : PM Client End Time (^) : PM Billable Time (^) 0.00 UNITS Staff Start Time (^) : PM Staff End Time (^) : PM Total Time (^) 0.00 UNITS Program RU < Location < Other: Modifier < ISP GOAL(S) ADDRESSED: #1 ; #2 ; #3 ; # INTERVENTION PSYCHOEDUCATIONAL: CLIENT PSYCHOEDUCATIONAL: PARENT RELAXATION SKILLS
AFFECT EXPRESSION COGNITIVE COPING TECHNIQUES INVIVO DESENSITIZATION
Narrative therapy techniques Safety planning Identify and correct cognitive distortions Preparation of child for sharing narration with parent using CBT and client centered techniques Other: Other: Identify and correct cognitive distortions Behavior management techniques Preparation of parent for sharing of narration Other: Other: Other: Briefly Describe : Progress: N/A No Change Deterioration Improvement: If Deterioration or Improvement Noted, Briefly Describe Significant Life Changes/Events : N/A Yes, Explain: Recommend Modification to ISP : No Yes, refer to MHA Update Change in Risk to Self or Others : No Yes, refer to MHA update; Suicide Assessment; Duty to Protect My signature verifies that service occurred as documented on this progress note. I authorize Bellefaire/JCB to bill for the time documented as “billable” above.
STAFF SIGNATURE CREDENTIAL DATE
SUPERVISOR SIGNATURE (If Applicable) CREDENTIAL DATE Conversion chart: > March 2010
Counseling Progress Note 2010-04- Client Name: Client ID: Staff Name: Staff ID: Date of Service Start Time □ am □ pm End Time □ am □ pm M M D D Y Y Y Y
Program: CTU Counseling Team: Service Code: H0004 □ HE - face-to- face □ HQ- group
# in group Client Location
(check only one) □^ 53- GCB^ □^ 12- Client Home^ □^ 99-Community^ □^ 51- Summit^ □ 09- Incarcerated^ □^ UK^ -^ client not present^
Date entered: Observed/Reported changes in condition: None Stressors/Extraordinary Events: None No significant change from last visit Client Condition Appearance unusual/bizarre poor hygiene appropriate casual and neat fastidious appears younger apprehensive inappropriate unkempt disheveled appears older other: Behavior cooperative guarded aggressive passive agitated unusual/bizarre impulsive fearful dramatic other: Stream of Thought clear & coherent impoverished rapid flight of ideas incoherent fragmented disordered loose tangential other: Abnormalities of Thought Content none phobias concrete thinking paranoid ideation delusions overvalued ideas ideas of reference poverty of thought obsessions other: Perceptual Disturbances none depersonalization derealization auditory visual illusions tactile olfactory other: Affect appropriate inappropriate expansive guilty bright congruent incongruent labile heightened depressed full range constricted blunted flat other: Mood euthymia elevated euphoria angry/irritable apprehensive anxious depressed dysphoria apathetic other: Orientation oriented x 3 not time not place not person Insight present adequate limited impaired faulty Judgment good fair impaired poor grossly inadequate Affix CLIENT label Affix STAFF label Greater Cincinnati Behavioral Health Services Counseling Progress Note
Counseling Progress Note 2010-04- Client Name: Client ID: Issue(s) presented today: symptoms or impairment such as attitudes about illness: early life experiences: emotional distress: maladaptive behavior patterns: personality growth and development: stabilization of mental status or functioning: issues related to establishing therapeutic relationship: coping strategies or techniques: other: Goal(s)/Objective(s) Addressed from ISP: Recommended Revision to ISP: None Revise ISP Therapeutic interventions provided OR Group Topic/Activity/Intervention Response to intervention/Progress toward goals OR Group Participation Additional information/Plan Provider Signature/Credential: Date: Client Signature (Optional Based on Client Preference): Date: _____________ Counter-Signature/Credential: Date: Date/Time of next Appointment: Client rating of progress: (write number in box) Have you made progress toward your goals today? ( Not Rated = 0 ; None = 1 Some Progress = 2 ; or Good Progress= 3 Affix CLIENT label Greater Cincinnati Behavioral Health Services Counseling Progress Note
OUTPATIENT PSYCHIATRIC CLINIC 2121 Main Street Raleigh, NC 27894 919-291- Date of Exam: 3/13/ Time of Exam: 10:45 am Patient Name: Smith, Anna Patient Number: 1000010544165 TREATMENT PLAN FOR ANNA SMITH Treatment Plan Meeting A Treatment Plan meeting was held today, 3/13/2012, for Anna Smith. Diagnosis: Axis I: Generalized Anxiety Disorder, 300.02 (Active) Axis II: None V71. Axis III: See Medical History Axis IV: None Axis V: 60 Current Psychotropics: Paxil 10 mg PO QAM Buspirone 10 mg PO QAM Ambien CR 6.25 mg PO QHS Synthroid 50 mcg PO QAM Problems: Problem #1: anxiety
Problem = ANXIETY Anna's anxiety has been identified as an active problem in need of treatment. It is primarily manifested by: Generalized Anxiety Disorder - with excessive worrying - with impairment in functioning. Long Term Goal(s):
- will reduce overall level, frequency, and intensity of anxiety so that daily functioning is not impaired. Target Date: 4/25/ Short Term Goal(s): Anna will have anxiety symptoms less than 50% of the time for one month. Target Date: 4/25/ In addition, Anna will exhibit increased self-confidence as reported by client on a self-report 0-10 scale weekly for two months. Target Date: 5/13/ Intervention(s):
- Prescriber to monitor side effects and ADJUST MEDICATION DOSAGE to increase effectiveness and decrease SIDE EFFECTS, as appropriate for anxiety disorder once per week for one month. Comprehensive Treatment Plan Barriers Emotional problems interfere with treatment.
- Anna is fearful that her apprehensive symptoms will never be under good control. Comprehensive Treatment Plan Strengths Anna's strengths include: cognitive
- Intellectually bright communicative
- Has good communicative skills family
- Good relationship with family
