This is one of the clearest breakdowns of psychotherapy vs. progress notes I have ever heard. You never cease to break down complex concepts clearly. Especially the idea that you can't "hide" things in process notes that are relevant to the treatment (examples would include when the client is having an affair or doing drugs). You go girl!

@MaelisaMcCaffrey

Жыл бұрын

Thanks, Barbara! That means a lot coming from someone who really knows her stuff regarding documentation!!!

Thanks very much for breaking down the difference between process and progress notes, Dr. McCaffrey! The detail and examples you provided were very helpful!

Thank you for this clear differentiation! So helpful. One question. How do you document email exchanges with a client?

Thank you as always for all the information you share so graciously. Could you please define ”clinically relevant information?”

@MaelisaMcCaffrey

Жыл бұрын

This question is actually the focus of next week's video! But for a sneak peek... think about info that you or someone else would need to adequately treat your client, and/or info that someone else would need to know that you did your due diligence. More to come on that one!

This is excellent content! So ian insurance for example can ask for progress notes or medical records? And what is the difference? What must be provided to insurance?

Question: What about "positive" symptoms or observations in our notes? comming from a CMHC, we were always encouraged to avoid them, it would cause insurance not to pay because the Client was "better". I think that logic is nuts, but I often think insurance companies are nuts too! :) 🙃

@marinaton

Жыл бұрын

Unfortunately, you are right. From experience I can say that the minute you report a lot of positive changes in the client, their insurance immediately stops authorizing additional sessions.

I researched process notes a couple years ago and found that even though they are our notes, it is the client’s information, meaning it’s up to the client whether they want them released as a result of a subpoena. I do not recall where I found this or if it was specific to my state. I hope if it came down to it, a client would understand they likely don’t want the process notes accessed. But like another commenter, I’m still hazy on “clinically relevant information”. Would it be ok to keep in a process note more detailed information about a client’s symptoms such as content of psychosis, obsession, rumination, etc. while in the progress note we generally summarize.

@marinaton

Жыл бұрын

I think you are absolutely right. The information in the process notes is clinically relevant, but it's more detailed and it doesn't have to go into progress notes because progress notes is more of a bureaucratic requirement of the insurance companies because, as the name implies, insurances give authorization for therapy sessions based on how clients are progressing. That's why there are specific things that have to be included in progress notes, but process notes can include anything. Whatever they include though is clinically relevant of course. Otherwise why would you put it in there? It may not be clinically relevant for the insurance company, but it's clinically relevant to you.

Does anyone know where I can find some samples of process notes? Because there are no rules, I do not understand what I need and don't need to write down. I feel like I am writing a chapter out of a book after each session because I am afraid I will need to remember every little detail. I would appreciate some more advice on what counselors do and do not usually include in their process notes. Thanks in advance!

@MaelisaMcCaffrey

Жыл бұрын

Perhaps it would be better to give yourself permission to NOT write process notes? They are only worth doing if they are useful for you personally, since they're not required. Focus on your progress notes and don't even worry about process notes ;)

For how long am I required to keep my process notes?

@marinaton

Жыл бұрын

In California I think it's 7 years.

Seems a bit tedious if I want to keep everything electronic in the EHR and then have a folder of notes that I did during each session just to remember for when I do a note and typing it into the process notes part of the EHR is redundant...everything I wrote is put into the note anyway. I use initials only and no other PHI is involved and seems unnecessary to keep these in a formal way. Does anyone do anything different than this?

@MaelisaMcCaffrey

Жыл бұрын

Hi Mark, You can simply shred the paper notes once you're done with them! Psychotherapy/process notes are NOT required so there is no need to keep them, or even to complete them in the first place.

@cns7404

Жыл бұрын

I shredd the process notes after the session because I put the relevant info progress notes. 😊

How relevant are "target dates" for completing treat plan goals? Other than seemingly good practice, do insurance companies factor in these dates for "medical necessity"?

@MaelisaMcCaffrey

Жыл бұрын

Medical necessity should dictate target dates but if you want a generic rule, think about reviewing your target dates for accuracy and updates every six months.