Documentation is one of the biggest hassles in any therapy job. It’s really no different in private practice. There are some basic parts of your therapy that need to be documented for insurance panels to cover you as a provider. This article will help you learn some documentation basics to reduce problems that can happen when you aren’t documenting well.

Before I started my practice, I had the idea that I wouldn’t have to do as much paperwork. Unfortunately, that’s not the truth. If you take insurances, you will be required to keep certain documentation. The insurance companies want to know they are getting something for their money. And even if you have a cash based practice, you need to do some paperwork to keep therapy on task and track client progress.

If it’s not documented, it didn’t happen.

Think about this for a moment and imagine the negative situations that could arise if you didn’t keep documentation. All kinds of things could go wrong and you would have no way to say what happened.

Progress Notes

Progress notes need to be written for each session you have with a client. They should be based on the client’s treatment plan and describe the progress the client is making on treatment plan goals. You can deviate from the treatment plan in a session. However, this should be documented in the progress note. An example is to write, “Client was in crisis over housing issues so therapist deviated from treatment plan goal of working on addiction triggers.”

There are two basic ways to handle your progress notes:

  • S.O.A.P. notes
  • D.A.P. notes

Treatment Plan

A treatment plan includes the client’s goals for therapy. Clients need an initial treatment plan when they begin therapy. Then, it should be updated every 120 days or 15 sessions (whichever comes first) for mental health clients. Drug and Alcohol clients generally have treatment plans which are updated every 90 days.

Treatment plans should be individualized so that every client’s treatment plan is different. You can begin a treatment plan with the client’s diagnosis. You should include the client’s problem list which can be written as a problem statement. A problem statement is a statement of the client’s problem from the client’s perspective. The following two sections include examples of problem statements and the problem list from those statements.

Example of Problem Statements

I feel depressed all the time, I want to sleep all day and I feel unmotivated to do anything.

I want to stop using drugs but my life is a mess. I’m in trouble with the law, my family hates me and I can’t get a job.

Example of Problem List

  • Depressed
  • Hypersomnia
  • Unmotivated
  • Drug use
  • Legal issues
  • Family issues
  • Underemployment

While we know these two examples of clients probably have more problems than they have listed, these are the issues as the client sees them. You want to work on the problems that the client recognizes and is willing to work on. Otherwise, you won’t make any progress. If you think the problem is the client’s drug use and they think the problem is their family hates them, forcing them to work on drug use won’t work. Instead, start with the family issues and ask them questions that make them realize for themselves that their family issues are a result of their drug use.

Always meet the client where they are!

Treatment plans should include measurable goals and objectives that are clear and time specific. An example is client will make themselves employable (goal) by obtaining a driver’s license (objective) in 4 months (time frame). It is measurable because you can tell it is completed when the client gets a driver’s license. You can include a plan for meeting goals and objectives. An example plan might be that client will take a driver’s education course at the community college which is completed in 8 weeks.

Client History

It’s important to write a biopsychsocial and determine a diagnosis for a new client. The best way to get the information you need for the client’s biopsychsocial and diagnosis is to take a client history. The client history can cover a number of topics but there are a few basics that most insurances require.

  • Basic information like name, address, date of birth, social security number, marital status, emergency contact, guardian (for minor)
  • Mental status, affect, speech, cognition, judgement, insight, attention span, memory, impulse control, suicidal/homicidal ideation
  • Medical condition, medications, allergies
  • Previous psychiatric treatment, hospitalizations, therapy, interventions used and outcomes
  • Substance abuse history including cigarettes, alcohol, drugs and over the counter drugs
  • Diagnosis
  • Culturally relevant information (which may need to be addressed in treatment plan) such as race, religion, ethnicity, gender, sexual orientation, socioeconomic class, level of education

Biopsychosocial

  • Presenting problem (and basic information)
  • Medical and Developmental history
  • Social and Recreational history
  • Family history
  • Relationship and children information
  • Education and Employment history
  • Military and legal history
  • Substance abuse history
  • Assessment (clinical impressions, client strengths and weaknesses, issues that could interfere with treatment, willingness to take part in treatment, motivation for treatment)
  • Diagnosis
  • Global Assessment of Functioning (GAF)

Note on DSM 5

While I have moved to using DSM 5 in my practice which does not use Axis and GAF, I have found that some insurances still ask for information on the Axis and GAF. I try to write my diagnosis more in paragraph form but include information that would normally be on each Axis. This way I have the information if they contact me for an update on client’s progress.