Documentation is not the fun part of being a therapist. Most of us don’t enjoy it at all. But documentation has to be done for insurance reimbursement. Regular documentation reviews can help you keep your documentation up to the highest standard. Learn how to review your documentation with the eye of an auditor.

The best advice is to document so that someone reading it can get a clear picture of what happened without being there.

How do you know if you are doing a good job documenting before you get audited? You can do regular documentation reviews to see if you are writing in a way that someone can understand it. Documentation reviews should be done with the thought, “would someone understand this who never met the client?”

Questions for Documentation Reviews

  • Would they know what the client’s issues are?
  • Would they know what you have done?
  • Would they know what the client has done?
  • Would they know what progress or lack of progress was made?
  • Would they know what techniques and interventions you used?
  • Would they know why you used techniques and interventions?
  • Would they know what referrals were made and who else was consulted?
  • Would they know what the client goals and objectives are?
  • Do the progress notes follow the treatment plan?
  • If the note doesn’t follow the treatment plan, is the reason noted?
  • Is the treatment plan regularly updated and changed when needed?
  • Are quarterly assessments of the treatment noted?
  • Have you documented each contact with the client?
  • Have you documented a termination letter was sent for discharges?
  • Have you documented why a client was discharged?

Checklist for Documentation Reviews

  • Legibility of writing
  • Use correct spelling, grammar and punctuation
  • Only use common abbreviations
  • Use black ink if handwriting notes
  • Use ballpoint pen to avoid smudging
  • Only use terminology you are trained to use
  • Errors are clearly documented by (Client was on time) error – initials, date and time
    • Place error in brackets
    • Cross out the error so it is still readable
    • Initial or sign
    • Date the error
    • Time the error
    • Never use correction fluid or tape
  • A copy of letters sent are in the chart and are documented in note
  • All documents are signed and dated with your credentials
  • Avoid blank space before the signature. If it cannot be avoided, draw a line after the last part of the note so it is clear nothing can be written in later.
  • Avoid using people’s names. Some counselor’s use the client’s first name but I believe it is more professional to use “client” instead. When writing letters where the name is needed, I use Mr./Ms./Mrs. Blank.
  • Notes are brief and concise. You don’t have to write everything that happened, just write a brief outline of the session and the most important points.
  • Notes are based on the treatment plan goals and objectives
  • Treatment plans have goals and objectives that are measurable and are updated regularly (usually every 4 months for mental health, 3 months for drug and alcohol)
  • Intake has insurance information, basic information like address, social security number, date of birth, emergency contact, etc.
  • HIPAA compliant
  • Termination letter, discharge summary and aftercare plan are noted.