By Kathleen McGlade, DSW, HIPAA Privacy Officer
Essentials of Documentation for Private Practice
By Kathleen McGlade, DSW, HIPAA Privacy Officer
Jewish Board of Family & Children’s Services
Changes in insurance audit practices and HIPAA’s (Health Insurance Portability
and Accountability Act) requirements for standard transactions and billing codes
have made case and accounting records a reality for social workers. Similar
to agency and hospital-based social workers, private practitioners are now challenged
to protect client confidentiality as they bill on line and prepare for audits.
Here are points to ponder in anticipation of the inevitable changes in record
keeping.
• Documentation is not a breach of clients’ rights to privacy; not
protecting it is.
• The basic components of a clinical record are demographics, referral
information, psycho-social assessment that supports a diagnosis, treatment plan
and progress notes.
• Record writing is not creative writing. Effective writing relies on
simple sentences and brevity that determine eligibility, substantiate diagnoses,
inform treatment, demonstrate progress and justify reimbursement.
• Since neither life nor treatment is predictable, a record acts as a
therapist’s compass.
• A record reveals logic. The reason for treatment, diagnosis, assessed
priorities, goals, time frames, and notes are separate parts of the same thread
that pull a case together.
• The same record can be useful to an auditor. Under federal law, HIPAA,
clients are advised of their rights to privacy and both a therapist’s
and insurance company’s obligations to protect it. Clients are advised
records are reviewed for reimbursement.
• Psychotherapy notes are defined specifically as notes documenting client-therapist
conversations. They are rarely kept except by students and for supervision.
They are not the same as session notes, are not filed in the record, and cannot
be accessed.
• Session notes describe pertinent points of a session as they relate
to the plan. They may include references to diagnosis, medication and client
behavior. They are filed in the record and can be accessed by insurers and clients
themselves.
• Sessions are intense; clients lead complex lives. As reminders and for
accuracy, social workers jot down thoughts or questions. Once used, such jottings
are shredded.
• Social workers do not file unread documents in records. For example,
if a medical report is provided by a client and is illegible, it is returned
or shredded.
• Protected information is kept on separate pages, for example, a family
member’s HIV status. Therapists review and remove such information before
releasing a record.
• Clients access records for such reasons as providing a new therapist
with information.
• Evidence of the legal status of caretakers and advocates for minor or
incompetent clients is kept in the record.
• Insurance companies have or will have required record formats for reimbursement.
• From day one, a therapist and client begin to define what is needed
for success. Insurers make this point by stating that the treatment plan is
the discharge plan.
• Unexpected events or obstacles are documented to explain the need for
more time.
• Notes are dated and include the name of the client and are initialed
by the therapist. They are best written in the present tense and on the day
of the event.
• Records do not contain hearsay, unsubstantiated opinions or judgments,
secrets, or charged words; they do contain facts and describe behavior.
• While a client quote may be relevant, statements from other professionals
or family members are best recorded in context and paraphrased. Quotes are often
later denied.
• Billing can be kept in client records. However, an accompanying administrative
file can be of use for such things as mandated reporting or improperly completed
releases.
• Records need to be kept safe and secure; fax machines, cell phones,
computer disks and laptops need the same protection as paper, voice mail, file
cabinets and PCs.
• NY State requires practitioners to keep client electronic and/or paper
records for seven years; it requires records of minor clients be kept until
they are 22 years old.
• A private practitioner is wise to have a simple document that outlines
his/her procedures for such activities as closing, transferring or destroying
case records.
• Don’t buy billing software yet; wait until insurers have worked
out their kinks.
• Avoid the suggestion of keeping two records.
• Stay informed of NASW updates on insurance companies’ audit procedures
.
Accurate records that reflect competence, use a payer’s approved format, and are focused on the essentials of treatment are likely to satisfy insurance companies and social work ethics. Shortly, NYC-NASW will sponsor a training session on writing records. It will include practical guidelines for documenting client history, assessments, and treatment plans, as well as an emphasis on the content of notes.r